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Crozier-Shaw et al. Neuroimmunol Neuroinflammation 2020;7:335-44 I http://dx.doi.org/10.20517/2347-8659.2019.005 Page 341

herniations. There were no statistitically significant improvements in patients who underwent surgery for
[33]
cervical stenosis or spondylosis .

Another retrospective cohort study of traumatic central cord syndrome, consisting of 126 patients, did
not demonstrate any statistically significance difference in neurological recovery based on the timing of
[34]
surgery. Patients in this cohort treated with surgery did have a shortened length of hospital stay .
A prospective cohort analysis of 98 patients with traumatic cervical SCI has showed that early surgical
decompression (within 24 h) demonstrated higher rates of ASIA grade recovery post-operatively. At
6 months post-operatively, 23% of the early surgical group had an ASIA grade improvement of at least two
[35]
grades, compared with 8.7% of the later surgical group .

Acute traumatic conus medullaris injury in spinal trauma between levels T12 and L1 has not been shown
[7]
to have any correlation between neurologic recovery and timing of surgery . The same author performed
another retrospective cohort analysis of patients with complete traumatic thoracic SCIs. A cohort of
12 patients showed that in complete thoracic SCIs, two patients demonstrated some sensori-motor
improvement, and one patient had motor functional improvement. The median time to surgery in these
patients was 11 days, ranging from one to 36 days. In all patients with a documented mechanism of injury,
[6]
they were all high-energy road traffic accidents, either in vehicles or on motorcycles .
However, surgical treatment in traumatic SCI, whether complete or incomplete, is controversial.
Conservative management of traumatic SCI has been described in the literature and was utilised to a
greater extent in the past. A retrospective cohort analysis published in 1987 reviewed the outcomes of 207
patients with traumatic SCI; 56% of this cohort underwent spinal surgery. There was however, no statistical
difference between the patients who underwent surgical treatment versus those managed conservatively in
[36]
terms of length of stay or neurological recovery . More recently, El Masri et al. discussed the evidence
[37]
for surgical management compared with Active Physiological Conservative Management. He concluded
that conservative, non-surgical management in patients with incomplete SCIs will often recovery enough
power to ambulate and suggested the need for review of the current standards of care in relation to the
acute management of traumatic SCIs.

The findings of these studies are certainly at odds with the approach to acute traumatic SCI in a study
[38]
published in 2010. Fehlings et al. assessed the professional opinions and clinical approaches to traumatic
SCIs in 972 spinal surgeons. 80% of the surveyed participants would prefer to decompress within 24 h.

Early and aggressive medical management of these patients, followed by appropriate surgical decompression
has demonstrated, in prospective studies, improvement of at least one ASIA grade in complete SCIs at one
year follow up in 60% of patients. 92% of patients with incomplete cervical spine injuries demonstrated
improvement at one-year follow-up in the same study.

CONCLUSION
SCI carries significant morbidity for affected patients and has a serious economic burden on society.
As illustrated by evidence from both the pathophysiology of SCI and clinical outcomes, timing is the
key variable that determines treatment outcomes. The acute inflammatory response responsible for
demyelination and neuronal damage occurs within minutes of the injury, but peaks at four days after. The
vascular and cellular sequelae of these acute inflammatory events, a direct response to trauma and injury,
exacerbate the damage and the degree of injury. If clinicians can intervene with the appropriate support
to delay, offset or reverse this catastrophic cascade of pro-inflammatory cytokines and ischaemia, patient
outcomes will obviously be greatly improved. These interventions must be timely, given how rapidly these