Early vs late surgical decompression for patients with acute traumatic central cord syndrome: a systematic review and meta-analysis

Introduction: The optimal decompression time for patients presenting with acute traumatic central cord syndrome (ATCCS) has been debated, and a high level of evidence is lacking. This systematic review and meta-analysis aim to compare early ( < 24 hours) versus late (≥24 hours) surgical decompression for ATCCS.

Methods: Medline, PubMed, and Embase, and CENTRAL were searched from inception to March 15th, 2023. The primary outcome was American Spinal Injury Association (ASIA) motor score. Secondary outcomes were venous thromboembolism (VTE), total complications, overall mortality, hospital length of stay (LOS), and ICU LOS. The GRADE approach determined certainty in evidence. PROSPEROID# CRD42023423866.

Results: The 9 studies included reported on 5619 patients, of whom 2099 (37.35%) underwent early decompression and 3520 (62.65%) underwent late decompression. The mean age (53.3 vs 56.2 years, p=0.505) and admission ASIA motor score (mean difference [MD]=-0.31 [-3.61, 2.98], p=0.85) were similar between the early and late decompression groups. At 6-month follow-up, the 2 groups were similar in ASIA motor score (MD= -3.30 [-8.24, 1.65], p=0.19). However, at 1-year follow-up, the early decompression group had a higher ASIA motor score than the late decompression group in total (MD=4.89 [2.89, 6.88], p< 0.001, evidence: moderate), upper extremities (MD=2.59 [0.82, 4.36], p=0.004) and lower extremities (MD=1.08 [0.34, 1.83], p=0.004). Early decompression was also associated with lower VTE (odds ratio [OR]= 0.41 [0.26, 0.65], p=0.001, evidence: moderate), total complications (OR=0.53 [0.42, 0.67], p< 0.001, evidence: moderate), and hospital LOS (MD=-2.94 days [-3.83, -2.04], p< 0.001, evidence: moderate). Finally, ICU LOS (MD=-0.69 days [-1.65, 0.28], p=0.16, evidence: very low) and overall mortality (OR=1.35 [0.93, 1.94], p=0.11, evidence: moderate) were similar between the 2 groups.

Conclusion : The meta-analysis of these studies demonstrated that early decompression was beneficial in terms of ASIA motor score, VTE, complications, and hospital LOS. Furthermore, early decompression did not increase mortality odds. Although treatment decision-making has been individualized, early decompression should be considered for patients presenting with ATCCS, provided that the surgeon deems it appropriate.