The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data
The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data
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DOI：
10.1016/s1474-4422(20)30406-3
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发表时间：
2021-01-20
期刊：
影响因子：
48
通讯作者：
Fehlings, Michael G.
中科院分区：
文献类型：
--
作者：
Badhiwala, Jetan H.;Wilson, Jefferson R.;Fehlings, Michael G.
背景尽管对损伤脊髓进行早期减压有很强的生物学依据，但手术减压时机对急性脊髓损伤（SCI）的影响仍存在争议，临床实践中存在很大差异。我们的目的是客观地评估急性SCI减压手术的时机对长期神经系统outcome.Methods的影响，我们做了一个汇总分析的个体患者的数据来自四个独立的，前瞻性的，多中心的数据来源，包括1991年12月至2017年3月的数据。这些研究中有三项已经发表;其中只有一项研究以前专门分析了手术减压时机的影响。之所以选择这四个数据集，是因为它们是最高质量的急性SCI数据集之一，并且包含高度粒度的数据。应研究作者的要求获得个体患者数据。这些数据集中所有因急性SCI接受减压手术的患者均被纳入。患者被分层为早期（脊髓损伤后24小时）减压组。采用美国脊髓损伤协会（ASIA）或国际脊髓损伤神经学分类标准（ISNCSCI）检查评估神经功能结局。主要终点是脊髓损伤后1年运动总分从基线的变化。次要终点是ASIA损伤量表（AIS）分级和1年后上肢运动、下肢运动、轻触和针刺评分的变化。通过调整基线评分、年龄、损伤机制、AIS分级、损伤程度和甲基强的松龙给药的分层混合效应回归进行一期荟萃分析。通过感觉神经功能评分的平均差（MD）和AIS分级的共同比值比（cOR）以及相应的95% CI总结效应量。作为一个次要的分析，在总运动评分的变化对手术减压时间（h）作为一个连续变量进行回归，使用限制性三次样条调整相同的协变量作为在primary analysis.Findings我们确定了1548符合条件的患者从四个数据集。1031例患者（66.6%）在脊髓损伤后1年的结局数据可用。在脊髓损伤后1年，接受早期手术减压的患者（n = 528）比接受晚期减压手术的患者（n = 1020）恢复更好;运动总分提高23.7分（95% CI 19.2 - 28.2），而晚期手术组为19.7分（15.3 - 24.0）（MD 4.0分[1.7 - 6.3]; p = 0. 0006），轻触评分改善19.0分（15.1 - 23.0）vs 14.8分（11.2 - 18.4; MD 4.3 [1.6 - 7.0]; p = 0.针刺评分改善了18.3分（13.7 - 22.9）与14.2分（9.8 - 18 - 6; MD 4.0 [1.5 - 6 - 6]; p = 0.0020）。与晚期手术患者相比，早期减压患者术后1年的AIS分级也更好，表明损伤程度较轻（cOR 1.48 [95% CI 1 - 16 - 1.89]; p = 0.0019）。当手术减压的时间被模拟为一个连续变量时，在伤后的前24 - 36小时内，随着时间的增加，总运动评分的变化急剧下降（p
Background Although there is a strong biological rationale for early decompression of the injured spinal cord, the influence of the timing of surgical decompression for acute spinal cord injury (SCI) remains debated, with substantial variability in clinical practice. We aimed to objectively evaluate the effect of timing of decompressive surgery for acute SCI on long-term neurological outcomes.Methods We did a pooled analysis of individual patient data derived from four independent, prospective, multicentre data sources, including data from December, 1991, to March, 2017. Three of these studies had been published; of these, only one study previously specifically analysed the effect of the timing of surgical decompression. These four datasets were selected because they were among the highest quality acute SCI datasets available and contained highly granular data. Individual patient data were obtained by request from study authors. All patients who underwent decompressive surgery for acute SCI within these datasets were included. Patients were stratified into early (= 24 h after spinal injury) decompression groups. Neurological outcomes were assessed by American Spinal Injury Association (ASIA), or International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), examination. The primary endpoint was change in total motor score from baseline to 1 year after spinal injury. Secondary endpoints were ASIA Impairment Scale (AIS) grade and change in upper-extremity motor, lower-extremity motor, light touch, and pin prick scores after 1 year. One-stage meta-analyses were done by hierarchical mixed-effects regression adjusting for baseline score, age, mechanism of injury, AIS grade, level of injury, and administration of inethylprednisolone. Effect sizes were summarised by mean difference (MD) for sensoriinotor scores and common odds ratio (cOR) for AIS grade, with corresponding 95% CIs. As a secondary analysis, change in total motor score was regressed against time to surgical decompression (h) as a continuous variable, using a restricted cubic spline with adjustment for the same covariates as in the primary analysis.Findings We identified 1548 eligible patients from the four datasets. Outcome data at 1 year after spinal injury were available for 1031 patients (66.6%). Patients who underwent early surgical decompression (n=528) experienced greater recovery than patients who had late decompression surgery (n=1020) at 1 year after spinal injury; total motor scores improved by 23.7 points (95% CI 19.2-28.2) in the early surgery group versus 19.7 points (15.3-24.0) in the late surgery group (MD 4.0 points [1.7-6.3]; p=0. 0006), light touch scores improved by 19.0 points (15.1-23 .0) vs 14.8 points (11.2-18.4; MD 4.3 [1.6-7.0]; p=0. 0021), and pin prick scores improved by 18.3 points (13.7-22.9) versus 14.2 points (9.8-18-6; MD 4.0 [1.5-6-6]; p=0.0020). Patients who had early decompression also had better AIS grades at 1 year after surgery, indicating less severe impairment, compared with patients who had late surgery (cOR 1.48 [95% CI 1-16-1.89]; p=0.0019). When time to surgical decompression was modelled as a continuous variable, there was a steep decline in change in total motor score with increasing time during the first 24-36 h after injury (p