Timing matters for spinal cord surgery: study

Dr. Fehlings performs spinal surgery in a recent handout photo. Timing appears to be everything when it comes to surgery in people who have suffered an upper spinal cord injury that can lead to quadriplegia, researchers say. THE CANADIAN PRESS/HO

TORONTO - Timing appears to be everything when it comes to surgery to help people who have suffered an upper spinal cord injury that can lead to quadriplegia, researchers say.

A Canadian-U.S. study of patients with trauma to the cervical spinal cord found that those who had decompression surgery within 24 hours of the injury had twice the chance of improved neurological recovery compared to those who had to wait longer for their operation.

The cervical spinal cord is encased in seven bony vertebrae that begin at the nape of the neck. Immediately below are the thoracic vertebrae, followed by those in the lumbar region that end in the tail bone.

The study focused on trauma to the cervical spine, the area which accounts for 30 per cent of all spinal cord injuries and can lead to a person becoming a quadriplegic.

"These are patients who have a very severe injury of the spinal cord," said Toronto neurosurgeon Dr. Michael Fehlings, who led the study.

Traumas that cause high-level spinal cord injury often occur from falls, sports injuries or motor vehicle accidents, said Fehlings, medical director of the Krembil Neuroscience Centre at Toronto Western Hospital.

"In most cases, there is a fracture of the cervical spine that results in either a dislocation of the vertebrae or a crush of one of the vertebra," he said. "Or in some cases, patients who have pre-existing narrowing of the spinal canal due to degenerative disc disease or arthritis can have blunt trauma injury to the cord without an actual fracture."

In the study of 313 patients with cervical spinal cord injury, published online Thursday in the journal PLoS ONE, almost 20 per cent of those who had decompression surgery on their spines within 24 hours showed marked improvement in function compared to less than nine per cent of those who had surgery later.

The operation involves releasing the pressure on the injured spinal cord and then stabilizing it.

Fehlings said better surgical techniques and advances in anesthesia over the last two decades have changed the view of operating on spinal cord injury patients as soon as possible.

"There's always been the concern that could one potentially harm the spinal cord by operating or are you benefiting and when should you do this?"

The study shows the sooner the better, he said.

“The differences that we are seeing with early decompression surgery are very significant and the results have a major impact on a person’s life,” said Fehlings. In rare cases, and depending on the severity of the injury, a patient who otherwise would likely have been paralyzed was able to walk.

Glenn Williams, 58, who lives near Barrie, Ont., north of Toronto, appears to have reaped the benefits of the surgery, which he had about 14 hours after slipping on an ice-slicked parking lot in 2008.

After falling flat on his back, he lay there with no feeling in most of his body.

"I couldn't move at all, nothing below the neck moved ... It was the scariest day of my life," said Williams, who was taken to a Barrie hospital, then transferred to Toronto Western, where Fehlings performed surgery.

Today, thanks to the operation and intense rehabilitation, Williams is walking. He still has some deficits, including overall weakness and numbness in one hand, but he sums up how he feels with one word: "Fortunate."

"I walk independently ... What Dr. Fehlings told me was that if it had happened 10 years before, I would have ended up in a wheelchair. I probably would have got some movement back, but not nearly what I have."

Fehlings said regional centres that specialize in traumatic spinal cord injuries should be created across Canada with the aim of providing patients, who may need to be transported from remote areas, more timely access to surgery.

"The timing for a spinal cord injury matters. In other words, it's like a stroke or a heart attack. Both stroke and heart attack (are) medical emergencies ... The same is true for spinal cord injury."

Dr. Brian Kwon, an orthopedic surgeon at Vancouver General Hospital, said the study's findings are "very important" for spinal surgeons like himself who have long wondered how critical the timing of surgery is in determining how patients may fare.

"The outcomes for it are promising in that the trial indicates that there is a potential neurological benefit to having surgery before 24 hours," said Kwon, who was not involved in the study.

"On balance, I think it would be fair to say patients had a higher chance of achieving what is considered considerable and meaningful recovery," said Kwon, sounding a note of caution.

"What that means is probably some improved hand function and maybe some improved trunk control, but not necessarily walking away from the injury."