Neurological Outcomes and The Role of Timing in the Surgical Management of Patients with Cervical Spinal Cord Injury Without Fracture and Dislocation: Systematic Review and Meta-analysis

Introduction: Cervical spinal cord injury (CSCI) can occur in the absence of easily identifiable osseoligamentous abnormalities, such as fractures and dislocations. The role of surgery in the management of CSCI without fracture and dislocation (CSCIWFD) remains to be elucidated.

Methods: A comprehensive literature search was conducted to identify studies investigating outcomes after surgical management of CSCIWFD. Random-effects model meta-analysis of pooled data was performed, with neurological improvement and time to surgery being the primary endpoints. Subgroup analysis by time to surgery was performed to assess improvement in neurological deficits between patients undergoing surgery acutely (within 72 hours of injury) versus later in the course (later than 72 hours after injury).

Results: Sixteen studies yielding 398 patients undergoing surgery for CSCIWFD were analyzed. The mean age at the time of injury was 52 ± 33.8 years, and male patients comprised 86.4% (95%CI: 76.6-94.4%). The mean number of spinal cord segments affected was 2.5 ± 4, with C5 (71%, 95%CI: 57.7-83.1%) being the most commonly affected segment, followed by C4 (68.7%, 95%CI: 48.3-86.6%). CSCIWFD was most commonly inflicted by falls (58.4%, 95%CI: 46.6-69.9%), followed by motor vehicle accidents (30.5%, 95%CI: 23.4-38%). Preoperatively, abnormal magnetic resonance imaging findings were observed in 125 patients (31.4%), and included: Intervertebral disc injury in 33 patients (26.4%); Cord edema in 23 patients (18.4%); Cord contusion in 22 patients (17.6%); Ligamentous injury in 6 patients (4.8%); MRI abnormalities not specified in 41 patients (32.8%). Postoperatively, neurological improvement was noted in 62% (95%CI: 21.4-95.2%) of patients who underwent surgery within 72 hours after injury, and in 71.1% (95%CI: 33-98.1%) of the patients who underwent surgery later than 72 hours after injury (p=0.8).

Conclusion : This meta-analysis demonstrated high rates of neurological improvement in patients treated surgically for CSCIWFD. No significant differences were noted between patients undergoing surgery acutely, within 72 hours after injury, and patients being treated surgically later in the course of CSCIWFD.