Acute traumatic spinal cord injuries - Are the current claims of superiority of outcomes of interventions on the injured spine evidence based?

Prior to WWII the majority patients with tSCI died in hospitals. There was however no shortage of Clinicians experimenting with the management of the injured spine. During WWII L. Guttmann (a well-trained aggressive Neurosurgeon) was given the task of looking after injured soldiers & officers with acute traumatic spinal cord and cauda equina ATSCI at Stoke Mandeville Hospital in the UK.    By studying the condition and the causes of death in a large number of patients, he realised that patients died or developed further neurological damage from various complications caused by the multi-organ Physiological impairment and malfunction caused by the damage to the neural tissue and not from the spinal injury (SI). He also observed that some patients died because of additional complications that developed during or following surgical interventions on the injured spine. By providing a Holistic Model of Service Delivery that attends to all the patho-physiological medical and non-medical effects of cord damage as well as the injured spine by what can be described as Active Physiological Conservative Management (APCM), Guttmann at Stoke Mandeville Hospital (SMH) demonstrated that all complications can be prevented or diagnosed and treated early and some patients exhibit various degrees of neurological recovery. Impressively, he demonstrated that the great majority of well managed patients could live long, healthy, dignified, productive and often competitive lives. In 1967 Frankel et al studied the neurological outcome of 612 patients treated by APCM admitted within 14 days of injury to SMH. They demonstrated that the majority of patients who retained sensory sparing but had no visible or palpable motor sparing following the injury exhibited some recovery of motor power. Folman and El Masri in 1989 explained that this recovery is likely to have been due to the proximity of the recovering initially dormant cortico-spinal tracts to the spared sensory tracts. Patients with some initial sensory and motor functions recovered relatively quicker and better. Surprisingly they found that such neurological recovery occurred irrespective of the severity of the radiological presentation on Xrays at admission (within 14 days of injury) and on discharge. They published their results in 1969 in what has been known since as the Frankel Classification. Their findings have been repeatedly confirmed over a period of more than five decades by various international groups of clinicians dedicated to the management of patients with tSCI Better visualisation of the injury by CT & MRI, improvement of spinal instrumentation and safety of anaesthesia since the 1980s encouraged the promotion of various spinal surgical interventions based on a range of assumptions. The assumption that spinal surgical decompression of the injured neural tissue within a “window of opportunity” of 8, 12 or 24 hours of injury is likely to halt many of the detrimental 2ry cellular and cell membrane disturbances; vascular, chemical, metabolic, inflammatory and enzymatic changes caused by the injury and improve the neurological outcome led to strong advocacy of and management by surgical decompression. Equally surgical reduction and stabilisation became strongly advocated on the assumption that this would enable to safely mobilise, rehabilitate and discharge the patient within a short period of hospitalisation. Unfortunately the effects of the disruption of blood the brain barrier and the loss of auto-regulatory functions of the injured neural tissue caused by the injury seem to have been overlooked. In the last four decades surgical decompression, realignment and stabilisation of the injured spine followed by early mobilisation of patients has become the current standard of care of management of the injured spine with or without attention to the range of effects of the neurological damage. To date (40 years since the change of practice in the management of the injured spine of patients with neurological damage from APCM to Surgical interventions) none of these assumptions have been justified by evidence of equality or superiority of neurological or other outcomes of any surgical intervention or a combination of interventions compared with the outcomes of APCM. Professor El Masri will discuss in some depth the relevance of the model of service delivery to patients and the level of evidence of those assumptions that led to change of practice in the management of these patients.