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Page 342 Crozier-Shaw et al. Neuroimmunol Neuroinflammation 2020;7:335-44 I http://dx.doi.org/10.20517/2347-8659.2019.005

celullar responses to injury occur.

Appropriate supportive therapy to maintain mean arterial pressure as described is essential. These
patients are often the victims of serious trauma events. As illustrated in the introduction, 40% of these
patients are involved in serious road traffic accidents, and may not be suitable for surgical intervention
due to concomitant injuries. Coagulopathy, acidosis or renal failure may all render a prolonged surgical
intervention dangerous [39-40] . It is in these circumstances that timely and appropriate management from
intensivists is paramount. This should, of course, be carried out in a multi-disciplinary manner, with input
from local neurosurgical or orthopaedic services.

Wherever possible, the prevailing standard of practice appears to guide surgeons to decompress the
injured spinal cord within 24 h of injury, particularly in incomplete injuries. This is illustrated by adapated
treatment algorithm in Figure 2. This has been shown to offer favourable outcomes in terms of neurologic
recovery, compared with delaying surgical intervention. Results are less favourable for patients with
complete cord injury. While some studies have offered equivocal results for early decompression, even in
incomplete injuries, such as central cord syndromes, the prevailing clinician preference is to decompress as
soon as possible.

While there has been a vogue for administering steroids acutely in these patients prior to decompression,
they appear to add little in terms of long-term recovery and should be discouraged.

LIMITATIONS
Conclusions drawn from this narrative review are derived from a combination of retrospective and
prospective cohort analyses, as well as questionnaire publications documenting the treatment preferences
of spine surgeons in their treatment protocols. While some evidence cited in this text does reach Level 1,
further investigations including randomised controlled trials and meta-analyses would benefit the evidence
base in terms of blood pressure management, steroids and surgical decompression.

SUMMARY OF RECOMMENDATIONS
(1) Patients with acute SCIs should have their mean arterial pressure maintained above 85-90 mmHg after
injury for a period of several days;
(2) Where possible, early surgical decompression within 24 h should be undertaken, particularly in
incomplete spinal cord injury;
(3) While the timing of establishing musculoskeletal stability of traumatic spinal injuries with surgical
decompression and fixation may not determine neurologic return, it certainly allows for earlier
mobilisation and easier nursing. This certainly explains the shorter lengths of stay and intensive care stays
noted in patients who undergo earlier surgery;
(4) Steroids appear to have no therapeutic value.

DECLARATIONS
Authors’ contributions
All authors contributed equally to the concepts, research, writing and overall academic workload in writing
this paper.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.