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Page 340 Crozier-Shaw et al. Neuroimmunol Neuroinflammation 2020;7:335-44 I http://dx.doi.org/10.20517/2347-8659.2019.005

mmHg is appropriate [25-27] . The duration of vasopressor support however, does not appear to be absolutely
supported in the literature. A systematic review of vasopressor support did mention that a duration of
five to seven days should be considered. The choice of vasopressor though does appear to be important
in some cohorts. A retrospective cohort analysis of 34 patients in California showed that in a subgroup of
patients over 55 years of age, dopamine produced statistically significant increases in the complication rates
when compared with phenylephrine [83% vs. 50% for dopamine and phenylephrine, respectively; OR with
[28]
dopamine 5.0 (95%CI: 0.99-25.34), P = 0.044] . This subgroup of 34 patients also demonstrated a median
improvement of one ASIA grade from admission to discharge, with no difference between vasopressor
agents.

Steroid administration
Steroids have traditionally been given in acute SCI. The hypothesis is that steroids reduce inflammation
and prevent secondary cord injury. However, a recent meta-analysis has debunked the evidence for
their routine use. A Cochrane review of three randomised controlled trials has shown no difference in
[29]
neurology between treatment and placebo groups at six and twelve months post-injury . Nevertheless,
despite the lack of evidence for routine administration of steroids in acute SCI, they appear to be routinely
administered in many institutions still. The rationale for this is varied, but the fear of medico-legal
consequences is one such reason. In the same study, surgeons also felt that there was little risk associated
with the routine administration of these treatments regardless, despite minimal demonstrated clinical
benefit .
[30]
Surgical treatment
Evidence suggests that decompression within 24 h of injury carries the greatest potential improvement in
neurologic function for patients with incomplete SCI after trauma.

The timing of surgical decompression is a factor that plays a role in neurologic recovery. There has been
some debate and certainly, this is a factor in the trauma patient with SCI and multiple concomitant injuries,
particularly chest injuries. Indeed, as discussed later, there is some evidence to suggest conservative
management will result in neurologic recovery also.

In a recent meta-analysis of nine studies, patients with traumatic SCIs who were decompressed within 24
hours had a significant neurologic improvement rate (OR = 1.66, 95%CI: 1.19-2.31, P < 0.01), a shorter
length of hospital stay by almost five days (P = 0.04) as well as fewer post-operative complications (OR =
[31]
0.61, 95%CI: 0.40-0.91, P = 0.02) . Surgery within 24 h for acute traumatic SCI is thus superior to delaying
surgery for neurologic outcomes.

[32]
In another meta-analysis performed by Ter-Wengel et al. , 422 patients with complete cervical traumatic
SCI showed that improvement was more likely after early surgery [respectively, 22.6%, 95%CI: 16.6%-
28.7% and 10.4%, 95%CI: 5.6%-15.8%; OR = 2.6 (95%CI: 1.4-5.1)]. The same meta-analysis showed that
in 636 patients with incomplete cervical traumatic SCI, there were no differences between early or late
surgery. The authors thus suggest a shift in the treatment of patients with complete cervical traumatic SCI.
The authors’ previous understanding of the literature was that there was equivocal evidence for recovery
in complete traumatic cervical SCI. The findings from this study changed that previously held position,
in favour of early surgical decompression. In incomplete cervical traumatic SCI, neurological outcome is
[32]
similar between early and late surgery .
In traumatic central cord syndrome, a retrospective cohort analysis of 50 patients treated acutely (within 24 h)
was noted to have shorter intensive care stay, overall length of stay and greater motor improvement (P =
0.04) compared with those decompressed later. This was only noted to be the case in acute fractures or disc