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13
FactorsAffectingSurgicalDecision
MakingintheManagementofSpinalCord
Injury
SoKato,SatoshiNori,andMichaelG.Fehlings
INTRODUCTION
Theincidence of traumaticspinalcord injury (SCI) anditsassociated surgical
interventionshavebeenslowlyrisingduetoanincreasingpopulationandaging
society(1).Theprimaryobjectiveofsurgicalinterventionistodecompressthe
spinal cord and regain stability of the spinal axis to optimize the local
environment for neurological recovery. As surgical techniques, anesthetic
protocols,andperioperativemanagementstrategieshaveevolved,thesafetyand
efficacy of operative intervention for SCI have improved, and as a result the
willingnesstohandlepatientswithcomplexcomorbiditieshasalsoincreased.
Theoutcomeofsurgicalinterventionshasagreatimpactonpatients’quality
of life (2), and the societal cost associated with SCI treatment is a huge
economic burden. Despite its critical importance, a consensus regarding
treatment strategy has not been fully established and there are several
controversiesregardingsurgicaldecisionmaking.Thepurposeofthischapteris
to review the current knowledge regarding factors affecting surgical decision
makinginSCI and to provide our own perspectives onthischallengingtopic.
The main issues addressed in this chapter are injury classification, timing of
surgicaldecompression,surgicaltechniques,andpatientcomorbidities.
INJURYCLASSIFICATION
To determine the operative indications for surgical intervention in cases of
traumaticSCI,athoroughassessmentofinjurytypesandneurologicalstatusis
mandatory.Currently,therearevariousclassificationstocharacterizedamageto
thespinalaxis.
SubaxialCervicalSpine
The AOSpine recently developed and established a classification system to
characterizesubaxialcervicalspineinjury(3).Thisclassificationmainlyfocuses
onthemorphologyandmechanismofinjury,anditisusefulforcommunication
amonghealthcare providers and better definitionsfromaresearch perspective.
Todirectlyanswerthequestionofindicationsforoperativetreatment,however,
theSubaxialCervicalSpineInjuryClassificationSystem(SLICS)score,which
wasdevelopedin2007andhasbeenwidelyusedthereafter,explainswhatcases
shouldbetreatedoperativelyinamoreintuitiveway(Table13.1;4).TheSLICS
score assesses three categories that characterize the injury: morphology
(compression, burst, distraction, and rotation/translation), damage to
discoligamentouscomplex(DLC),andneurologicaldeficits.Scoresareassigned
in each category, and when the sum of the three scores is above four points,
operative management is indicated, while nonoperative management is
recommended in patients where the sum of scores is less than four points.
MorphologyandDLCscoresfocusonspinalstability,withhigherscoresbeing
assignedwherethespineismoreunstable.Generally,instabilityisdependenton
thenumberofcolumnsdamagedaccordingtotheDenisclassification(anterior,
middle,andposterior)(5;Figure13.1).Neurologicalscoreweighsmoreincases
ofincompletecordinjuryascomparedtocompleteinjury,givenitspotentialfor
recoveryandtheurgencyofinterventionrequired.Nerverootinjury(i.e.,cauda
equina injury) is considered to have a better prognosis. The reliability and
validityoftheSLICShasbeenestablished(6).
ThoracolumbarSpine
Classification scores have also been proposed in thoracolumbar (considered
herein to include both the thoracic and lumbar spine) injuries. The Denis
classificationsystemcategorizestheinjuriesintofourtypesbasedontheextent
ofspinalcolumn disruption:compression, burst,seatbeltinjuries,and fracture
dislocations (5). Similarly to the subaxial cervical spine, the AOSpine also
developed a classification system for the thoracolumbar spine (7). The
Thoracolumbar Injury Classification and Severity (TLICS) system was
developedin 2005 (Table 13.2;8) precedingSLICS, which was modified and
appliedto thesubaxialcervical spinelater.Asisthe casewithSLICS, TLICS
analyzesinjurymorphology,theintegrityoftheposteriorligamentouscomplex
(PLC), and neurological status. Morphology correlates more with immediate
stability, while PLC integrity correlates with long-termstability. Integration of
PLC damage assessment is useful to differentiate chance fractures from burst
fractures.“C”hancefractureisacompressioninjurytotheanteriorportionofthe
vertebral body and a transverse fracture through the posterior elements of the
vertebraandtheposteriorportionofthevertebralbody,whichtherebyinvolves
PLC injury. It is also described as “flexion-distraction injury.” This type of
injury has been commonly seen in motor vehicle accidents with hyperflexion
force, also known as “seat belt injury.” It is clinically important for decision
making because chance fractures usually necessitate stabilization by posterior
tension band reconstruction, which is not the case for compression or burst
fractures.Similarly to SLICS,asummed score above fourpointsindicates the
need for surgicalintervention, and a summed score of fewer than four points
indicates that nonoperative management may be employed. Reliability and
validityoftheTLICShasbeenrepeatedlytestedandestablished,buttheoptimal
treatment strategy for thoracolumbar burst fractures is still controversial. The
vast majority of thoracolumbar burst fracturesare neurologicallyintact due to
the wide spinal canal at this point and they can be managed nonoperatively.
Thosewithsolitary radicularsymptoms,whichtypicallyresultinTLICS score
of4 (borderline), are known to have a good prognosis and surgical indication
shouldbedeterminedonacase-by-casebasisdepending onthe symptomsand
patients’physicalstate.
TABLE13.1SubaxialCervicalSpineInjuryClassificationSystem(SLICS)
TYPE POINTS
Morphology Compression 1
Burst 2
Distraction 3
Rotationortranslation 4
IntegrityofDLC Intact 0
Indeterminate 1
Disrupted 2
Neurologicstatus Intact 0
Nerverootinjury 1
Completecordinjury 2
Incompletecordinjury 3
Continuouscordcompression +1
DLC,discoligamentouscomplex.
Source:AdaptedfromVaccaroAR,HulbertRJ,PatelAA,etal.Thesubaxialcervicalspineinjury
classificationsystem:anovelapproachtorecognizetheimportanceofmorphology,neurology,andintegrity
ofthedisco-ligamentouscomplex.Spine(PhilaPa1976).2007;32:2365–2374.
doi:10.1097/BRS.0b013e3181557b92
SURGICALAPPROACHANDTECHNIQUESFOR
FIXATION
The classifications described earlier influence not only surgical indication but
also management strategies such as surgical approach and techniques of
stabilization. Given spinal axis stability is impaired to various extents in
traumatic SCI, spinal stabilization is almost always required. Decompression
procedures without fusion are seldom performed due to the risk of worsening
stabilityordeformitydevelopmentafterlaminectomyalone,withtheexception
oflaminoplastyforcentralcordsyndrome (CCS)without instability. Thereare
several options for surgical decompression and fixation in terms of surgical
approach(anterior versusposterior)and fixationtechniques.Surgicalapproach
selectiondependsonthepathologyofspinalcordcompressionandthedisrupted
spinalcomponentsthatleadtomechanicalinstability.
In the subaxial cervical spine, Dvorak et al. reported the algorithm using
SLICStoguidesurgeonstodeterminethesurgicalapproach(9).Burstfractures
involve the anterior and middle columns and the bone fragment from the
posteriorwallofthevertebralbodyencroachesthespinalcanal.Todecompress
and stabilize, the optimal approach is anterior corpectomy and fusion, in
combination with reconstruction by structural graft (e.g., cage, autograft, or
allograft).Incontrast,translation/dislocationisbetterhandled usingaposterior
approach. It is associated with solid fixation points by pedicle/lateral mass
screws,andfacetdislocationcan bedirectlymanipulatedbyopen reductionas
opposed to an anterior approach. One exception is that when translation is
associatedwithsignificantdischerniation,anteriordiscectomy andfusionwith
an attempt to reduce the alignment should be performed first, followed by
posterior reconstruction as needed. Hyperextension injury associated withstiff
spine, such as diffuse idiopathic skeletal hyperostosis (DISH) or ankylosing
spondylitis(AS),necessitatesstabilizationthatinvolvesalongleverarm,andis
readilytreated by posteriorfixationwith at leastthreelevels above andbelow
thefracturesite.Westerveldetal.reportedthatsurgerywasperformedin54.2%
offracturesassociatedwithASandconsistedmainlyofposteriorfixation(10).
The surgical approach for CCS is similar to that for degenerative cervical
myelopathy. Both anterior and posterior approaches have their pros and cons.
For example, anterior surgery is associated with the risk of postoperative
dysphagia and injuries to critical structures during approach (e.g., esophagus,
recurrentlaryngealnerve,andvertebralartery),whileposteriorsurgeryisknown
to have a higher risk of postoperative axial pain and C5 palsy. However,the
guidingprincipleistodeterminetheapproachthatcanmosteffectivelyaddress
thecompressiveandstabilizationfactors.
FIGURE13.1AnillustrationofDenis’sthreecolumnsinspine.
Source: Denis F.The three column spine and its significance in the classification of acute
thoracolumbar spinal injuries. Spine (Phila Pa 1976). 1983;8:817–831.
doi:10.1097/00007632-198311000-00003; With permission from BMJ Publishing Group:
http://bestpractice.bmj.com/best-practice/monograph/819.html
For thoracolumbar fractures, controversies exist with regard to the
effectivenessofeachapproach.Therehasbeenlittlestrongevidencetosupport
thesuperiorityofonespecificapproachorsurgicaltechniqueforthoracolumbar
burst fracture. As a trend, more and more injuries tend to be approached
posteriorly since pedicle screw–based fixation has become popularized, and
sophisticated decompression procedures such as transpedicular approach,
costotransversectomy, and various kinds ofosteotomieshavebeen established.
Nonetheless,anteriordecompressionstillhasseveraladvantagesincludingdirect
accesstothebony compressionandshorterlevelsoffixationand soshouldbe
performedinselectedcases.
TIMINGOFSURGICALDECOMPRESSION
Preclinicalanimalstudieshavedemonstratedthatpersistentcompressionofthe
spinal cord after the initial trauma causes ischemia and exacerbates the
secondaryinjurycascade(11,12).Accordingtoasystematicreviewofthetiming
ofsurgical interventioninpreclinical animal models, longerdurationof spinal
cordcompressionwasrelatedtogreaterlocalischemiaandlargerlesionvolume
aswellasworsenedmotorfunctional recovery (13). Another meta-analysisof
preclinical studies reported similar findings (14). From a clinical perspective,
early surgical decompression is performed to provide relief from mechanical
pressureinordertoreducespinalcordcompressionandischemia.
Following from these preclinical results, several studies have emerged to
elucidate the effectiveness of early decompression. The SurgicalTreatment of
Acute Spinal Cord Injury Study (STASCIS) was a prospective cohort study
conducted with 313 patients with cervical SCI (15). The early decompression
group(<24hoursafterSCI)was2.8timesaslikelytodemonstrateatleastatwogradeimprovementinASIAImpairmentScale(AIS)gradeat6monthsafterSCI
compared with the late decompression group (≥24 hours after SCI) after
adjustingforconfounders.However,itshouldbenotedthatthereanalysisofthe
raw data of the STASCIS study by van Middendorp et al. demonstrated a
tendency toward the efficacy of early decompression, but no statistically
significant difference (16). Subsequently,a prospective Canadian cohort study
that included 84 patients with cervical, thoracic, and lumbar SCI also
demonstratedthat surgeryperformed before 24hoursafter SCIwasassociated
withatleastatwo-gradeAISimprovementatthetimeofrehabilitationfacility
discharge(17). Another prospective cohort study compared early (≤24 hours)
with late (>24 hours) surgery for 888 patients with cervical, thoracic, and
thoracolumbar SCI (18). Patients with incomplete SCI (AIS B, C, and D)
demonstratedimprovement ofan additional6.3points inASIAmotorscorein
the early group compared with that in the late group. Furthermore, a
retrospectivestudyof70patientswithcervicalSCIshowedthatdecompression
conductedbefore8hoursafterSCIwasrelatedtobetterimprovementinSpinal
CordIndependenceMeasure(SCIM)scoresandAISgradesat1yearafterSCI
(19).Anotherprospectivecohort study focusing on cervical SCI demonstrated
thatearlysurgery(≤48hours)reducedpostoperativecomplications,daysinthe
intensivecareunit,andmortality(20).Interestingly,theultra-earlysurgery(≤4
hours)iscomparabletotheearlysurgery(between4and24hours)intermsof
AISimprovementinthe prospectivecohortstudy(21).Ontheotherhand, one
randomized, controlled trial comparing early (≤72 hours) with late (>5 days)
surgery for cervical SCI demonstrated that neurological recovery was not
different between the early and late surgery (22). However, the discrepancy
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