Spinal Cord Injury in the 21st Century Part III: A Systematic Meta-Analysis on the Timing of Surgery

Background: Studies on acute spinal cord injury from fracture or dislocation (SCIwiFD) suggest surgery within 48 hours of injury maximizes neurologic recovery. However, the optimal timing of surgery for patients suffering SCI without fracture or dislocation (SCIwoFD) has not been established. Our experience suggests a need to critically reevaluate the role of early surgery. Methods: We provide 2 illustrative cases raising concern for early surgery in SCIwoFD and performed a systematic meta-analysis examining differences in American Spinal Injury Association Motor Scores (AMS) for patients undergoing early (<48–96 hours from injury) versus late (>48–96 hours from injury) surgery. A random-effect meta-analysis was implemented using standardized mean difference (SMD) between baseline AMS and most recent follow-up to estimate effect size. Results: Seven studies met inclusion criteria, with 210 patients undergoing early surgery and 279 undergoing late surgery. Overall, an SMD of −1.1 (95% CI: −1.3 to −0.9) was found (I² = 64%, P < 0.001), indicating a 1-point improvement in AMS after surgery at any time point. When comparing SMD between subgroups, there was no significant difference in AMS from baseline to follow-up between those who underwent early surgery versus late surgery (P = 0.39, df = 1). Conclusions: While there is considerable heterogeneity in the data, there is no significant difference in neurologic recovery seen in patients with SCIwoFD who undergo early surgical intervention compared to those who undergo surgery in a delayed fashion. Our anecdotal experience underscores the need to critically reexamine timing of surgery in this population.