Beyond Guidelines
Time is Spine
This week, I was invited by our ICU colleagues to speak on the topic of acute spinal cord injuries. They were interested in knowing the current recommendations regarding when to operate.
To start off, I highlighted the widely cited STASCIS trial published over a decade ago, which recommends early surgery within 24 hours. This study demonstrated that early intervention leads to a better chance of neurological improvements (OR 2.83 ASIA grade ≥ 2) at 6 months.
The 24-hour recommendation has been supported by the AO Spine Praxis guidelines published in March this year.
However, the challenge has never been about meeting this 24-hour window, even within the constraints of our public hospital setting.
False Dichotomy
When faced with the option of surgery, individuals with a high-grade spinal cord injury often see it as their only hope for recovery, no matter how dismal the odds are.
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What is not widely understood is that the outcomes of surgery versus no surgery are not simply a matter of recovery versus non-recovery.
Whether surgeon or patient, there is a natural human bias towards action. An unwanted outcome following inaction leads to more negative feelings than an unwanted outcome resulting from action.
However, the physiological stress from subjecting an already frail patient to spine surgery can spiral into prolonged ICU stays, ventilator dependency, recurrent hospital-acquired infections, and, for some, progressive deterioration from respiratory failure.
Therefore, the true controversy is patient selection.
The polymorbid elderly patient with a complete high cervical injury will never regain significant function. Conversely, a young athlete with a partial cord injury will likely be back on his feet, potentially even without surgical intervention.
And then there are all the cases that fall somewhere in between, but current guidelines have yet to address this.
The ultimate discretion remains with the clinician, who delicately balances expectations with the realities of the situation.