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Spinal fixation surgery for acute traumatic spinal cord injury (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . .
ABSTRACT . . . . . . . . .
PLAIN LANGUAGE SUMMARY .
BACKGROUND . . . . . . .
OBJECTIVES . . . . . . . .
METHODS . . . . . . . . .
RESULTS . . . . . . . . . .
DISCUSSION . . . . . . . .
AUTHORS CONCLUSIONS . .
ACKNOWLEDGEMENTS
. . .
REFERENCES . . . . . . . .
CHARACTERISTICS OF STUDIES
DATA AND ANALYSES . . . . .
WHATS NEW . . . . . . . .
HISTORY . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS
DECLARATIONS OF INTEREST .
SOURCES OF SUPPORT . . . .
INDEX TERMS
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Spinal fixation surgery for acute traumatic spinal cord injury (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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[Intervention Review]
UK. 3 NHS Centre for Reviews and Dissemination, University of York, York, UK
Contact address: Anne-Marie Bagnall, Faculty of Health, Leeds Metropolitan University, Calverley Street, Leeds, LS1 3HE, UK.
A.Bagnall@leedsmet.ac.uk.
Editorial group: Cochrane Injuries Group.
Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 9 October 2007.
Citation: Bagnall AM, Jones L, Duffy S, Riemsma RP. Spinal fixation surgery for acute traumatic spinal cord injury. Cochrane Database
of Systematic Reviews 2008, Issue 1. Art. No.: CD004725. DOI: 10.1002/14651858.CD004725.pub2.
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ABSTRACT
Background
If the spine is unstable following traumatic spinal cord injury (SCI), surgical fusion and bracing may be necessary to obtain vertical
stability and prevent re-injury of the spinal cord from repeated movement of the unstable bony elements. It has been suggested that
this spinal fixation surgery may promote early rehabilitation and mobilisation.
Objectives
To answer the question: is there a difference in functional outcome and other commonly measured outcomes between people who have
a spinal cord injury and have had spinal fixation surgery and those who have not?
Search methods
The following databases were searched: AMED, CCTR, CINAHL, DARE, EMBASE, HEED, HMIC, MEDLINE, NRR, NHS EED.
Searches were updated in May 2003 and MEDLINE was searched again in May 2007. The reference lists of retrieved articles were
checked.
Selection criteria
Randomised controlled trials and controlled trials that compared surgical spinal fixation, with or without decompression, to any other
treatment, in patients with a traumatic SCI.
Data collection and analysis
Two reviewers independently selected studies. One reviewer assessed the quality of the studies and extracted data.
Main results
No randomised controlled trials or controlled trials were identified that compared surgical spinal fixation surgery to other treatments
in patients with a traumatic SCI. All of the studies identified were retrospective observational studies and of poor quality.
Spinal fixation surgery for acute traumatic spinal cord injury (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Authors conclusions
The current evidence does not enable conclusions to be drawn about the benefits or harms of spinal fixation surgery in patients with
traumatic SCI. Well-designed, prospective experimental studies with appropriately matched controls are needed.
BACKGROUND
There is no accepted figure for the incidence of new cases of acute
spinal cord injury (SCI) globally; estimates range from 10 to 83
cases per million population annually (Wyndaele 2006). It is estimated that between 500 and 700 people sustain a traumatic SCI
in the UK each year (Harrison 2000), and that there are approximately 10,000 new cases per year in the USA (McDonald 2002).
SCI can occur at any age. The effects are usually permanent and
currently there is no cure (Smith 1999). The modal age of SCI
is 19 years, most people with SCI then live a relatively normal
lifespan, so the lifetime cost of care may be quite high. The average lifetime cost of treating a person with SCI has been estimated at between US$500,000 and US$2 million, depending on
the extent and location of injury (McDonald 2002). The most
common mechanism of injury is a sudden unexpected impact or
deceleration (e.g. road traffic injury, domestic falls). Further neurological deterioration, resulting from lesion extension after the
initial injury, can occur naturally in about 5% of cases (Harrison
2000) and complications associated with the systemic effects of
SCI can lead to respiratory compromise. Significant delays and
complications - sometimes leading to admission to an intensive
therapy unit (ITU) can also arise as a result of inappropriate or
poorly informed management.
If the spine is unstable following injury, surgical fusion and bracing
may be necessary to obtain vertical stability and prevent re-injury
of the spinal cord from repeated movement of the unstable bony
elements (Geisler 1988). It has been suggested that spinal fixation
surgery may enable early rehabilitation and mobilisation. There
does not seem to be an accepted protocol with regard to what type
of surgery is used: whether surgical stabilisation or surgical decompression are required, and what type of approach, instrumentation
and procedure should be chosen. In some cases the procedure in-
Spinal fixation surgery for acute traumatic spinal cord injury (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
OBJECTIVES
The objective of this review is to answer the following research
questions:
1. Is there a difference in rate or completeness of neurological
recovery between those who have had spinal fixation surgery and
those who have not?
2. Does spinal fixation surgery have an effect on time to
mobilisation, acute recovery from trauma, pain, posture, spinal
deformity, surgical complications, post traumatic syrinx and
other generally measured outcomes?
The search strategy was devised to find papers about spinal fixation surgery for spinal cord injuries. This strategy combined terms
for spinal cord injury with terms for fixation and fusion. The
strategy also used specific search terms for spinal cord surgery,
but not broader search terms for spinal surgery in order to narrow
the search. The terms used in the search strategy were identified
through discussion with the research team involved in the HTA
review, by scanning background literature and by browsing the
MEDLINE thesaurus (MeSH).
Full details of the search strategies are available from the authors
and from Bagnall 2003 in electronic format.
Searches were conducted for the HTA review in October 2001.
The searches were updated for this Cochrane review in May 2003
and the MEDLINE search was updated in May 2007.
Types of participants
Electronic searches
METHODS
Types of studies
Types of interventions
Surgical spinal fixation (with or without surgical decompression)
compared to any other treatment. Studies which compared different types of surgical spinal fixation were not included. Studies
which included postoperative external bracing were eligible for inclusion in the review.
Spinal fixation surgery for acute traumatic spinal cord injury (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
RESULTS
Description of studies
See: Characteristics of excluded studies.
In the HTA review (Bagnall 2003), 68 studies were identified that
addressed the question of spinal fixation surgery for acute traumatic SCI. All studies included a control group, in that a group receiving spinal fixation surgery was compared to a group not receiving spinal fixation surgery. However, all studies were retrospective
observational studies and of poor quality. There was some doubt
over the comparability of groups and/or on confounding factors
in many of the studies. Often, the decision on whether to treat
surgically or not was made based on the severity of the patients
injuries (more severe injuries led to non-operative treatment in
some units and to operative treatment in others). In many studies, results of surgery with and without fixation were reported together. In a number of other studies, few details of baseline severity
or patient demographics were reported. A full discussion of these
studies, including full data extraction and quality assessment tables, is available in the HTA review.
Update searches, conducted for this review in May 2003 and May
2007, located a further 3106 records. Of these, 10 were retrieved
for full inspection. No relevant RCTs or controlled trials were
identified. The majority of the identified studies were retrospective case series and did not directly investigate whether spinal fixation surgery resulted in better outcomes than no spinal fixation
surgery. One study (Brodke 2003) compared anterior and posterior surgical approaches in a RCT. Another study (Kerwin 2005)
was a retrospective review of the effects of spinal fixation within
3 days. One literature review (Kishan 2005) and one systematic
review (Fehlings 2006) were also found. Both suggested that early
decompression surgery may be beneficial, but did not find strong
evidence about the effects of spinal fixation surgery.
Effects of interventions
No studies were included.
DISCUSSION
Spinal fixation surgery for acute traumatic spinal cord injury (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
AUTHORS CONCLUSIONS
Implications for practice
The current evidence is insufficient to enable the author to comment on the benefits or harms of spinal fixation surgery in patients
with traumatic SCI.
ACKNOWLEDGEMENTS
We wish to thank Steven Duffy for conducting the initial and
2003 update searches for this review.
REFERENCES
Spinal fixation surgery for acute traumatic spinal cord injury (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Geisler 1988
Geisler FH. Acute management of cervical spinal cord
injury. Maryland Medical Journal 1988;37(7):52530.
Harrison 2000
Harrison P. Managing spinal injury: critical care. the initial
management of people with actual or suspected spinal cord
injury in high dependency and intensive care units. Spinal
Injuries Association. London, 2000.
McDonald 2002
McDonald JW, Sadowsky C. Spinal-cord injury. Lancet
2002;359(9304):41725.
Additional references
Amar 1999
Amar AP, Levy ML. Surgical controversies in the
management of spinal cord injury. Journal of the American
College of Surgeons 1999;188(5):55066.
British Orthopaedic
British Orthopaedic Association. The Initial Care and
Transfer of Patients with Spinal Cord Injuries. British
Orthopaedic Association, 2006.
Donovan 1994
Donovan WH. Operative and nonoperative management of
spinal cord injury: a review. Paraplegia 1994;32(6):37588.
El Masri 2006
El Masri WS. Traumatic spinal cord injury: the relationship
between pathology and clinical implications. Trauma 2006;
8:2946.
Spinal fixation surgery for acute traumatic spinal cord injury (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CHARACTERISTICS OF STUDIES
Study
Brodke 2003
Fehlings 2006
Systematic review.
Kerwin 2005
Kishan 2005
Literature review.
La Rosa
Literature review.
McKinley
Moon
Sustic
Wang
Wang (b)
Spinal fixation surgery for acute traumatic spinal cord injury (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
WHATS NEW
Last assessed as up-to-date: 9 October 2007.
Date
Event
Description
11 September 2008
Amended
HISTORY
Protocol first published: Issue 2, 2004
Review first published: Issue 1, 2008
CONTRIBUTIONS OF AUTHORS
AM Bagnall - wrote protocol
L Jones - wrote protocol
S Duffy - designed and carried out search strategy
R Riemsma - oversaw project, provided comments and input at all stages
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
Centre for Reviews and Dissemination, University of York, UK.
Spinal fixation surgery for acute traumatic spinal cord injury (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
External sources
Health Technology Assessment (HTA) Programme, NHS, UK.
INDEX TERMS
Medical Subject Headings (MeSH)
Randomized Controlled Trials as Topic; Spinal Cord Injuries [ surgery]; Spinal Fusion [ methods]
Spinal fixation surgery for acute traumatic spinal cord injury (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.