Letter: Ultra-Early (<12 Hours) Surgery Correlates With Higher Rate of American Spinal Injury Association Impairment Scale Conversion After Cervical Spinal Cord Injury

To the Editor: We read with great interest the recent article by Burke et al1 on the timing for surgical decompression in patients with cervical spinal cord injury (CSCI). In a retrospective cohort of 48 patients with CSCI, the authors compared the status of neurological recovery between patients assigned into the ultra-early (<12 h, n = 18), early (12-24 h, n = 17), and late (>24 h, n = 13) surgery subgroups. With statistical analysis controlling for preoperative confounding factors including age, sex, injury severity score, and length of stay, the authors found that the ultra-early patient group experienced significantly better neurological improvement than other groups. These findings highlight the importance of early surgical intervention for CSCI patients in clinics and provide useful information for the management of this disease. Here, we would like to communicate with the authors regarding several issues on this topic. First, although early surgery appeared to confer more benefits to CSCI population as the authors suggested, it may not be appropriate for all patients in clinical practice. For example, patients with CSCI may possibly have multiple concurrent injuries,2 such as severe brain injury, pelvic fracture, or visceral hemorrhage, which can constitute a contraindication for early surgery among these individuals. In addition, other preoperative comorbidities (such as severe diabetes mellitus, chronic obstructive pulmonary disease, and acute lung or urinary tract infection) may also preclude early surgery for CSCI patients. Considering these issues, we suggest that a detailed description of these aspects should be provided for the study cohort as these coexisting pathologies before surgery may partly contribute to the worse neurological outcomes in patients who underwent late surgery. Second, although the authors concluded that late surgery (>12 h) offered no benefits for CSCI patients, we consider that surgery is still worthwhile under certain conditions,3 for instance, traumatic cervical dislocation and/or marked spinal cord compression. In these situations, surgery is able to reconstruct spinal stability and achieve complete decompression of the spinal cord, which thereby creates a favorable microenvironment for the recovery of neurological functions, and also prevents disease progression. Third, as the authors’ stated, surgical approach for the patients was determined by different surgeons in this study, which could cause heterogeneities on the reporting data between the 3 subgroups and then compromise the reliability of the results. Similarly, other influencing factors including level and type of injury, as well as the mean arterial blood pressure should also be adjusted in the statistical analysis as these parameters have been reported to affect the neurological functions of patients after surgery.4-6 Apart from this, recent studies have shown that neuroimaging features (specifically including axial diffusivity on diffusion tensor imaging, as well as midsagittal tissue bridges, size of T1-low intensity or T2 high-intensity area, ligamentous injury, and facet dislocation on magnetic resonance imaging) and the inflammatory cerebrospinal fluid (CSF) biomarkers can accurately reflect neurological prognosis in patients with CSCI.7-12 Furthermore, it has also been suggested that neurophysiological evaluation is an important predictive tool of functional outcomes for CSCI patients, which can even enhance the prognostic power of clinical variables in the outcome prediction.13 However, in this study, the authors failed to provide any information on radiological or CSF findings and neurophysiological examination of patients, which may further introduce bias to the results. Finally, this study only involved preliminary results and reported no data on physical rehabilitation course and drug therapies for each patient. In summary, we advocate that future prospective large sample studies with a long follow-up and more complete clinical data should be carried out to further confirm the current data. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.