The title of our talk is Ultra-Early Surgery, Less Than 12 Hours Correlates with Improvement in Motor Recovery After Cervical Spinal Cord Injury, a TREC SCI Study. I would like to thank the AANS, Dr. Sanjay Dahl, and all the TREC SCI researchers for this opportunity. I have no financial disclosures. In terms of background, spinal cord injury affects 17,000 patients a year, resulting in severe neurological injury. Early surgery after cervical spine may limit secondary injury, so there's been a push recently to try to essentially perform surgery after SCI in an early time window. 2017 consensus guidelines by Failings and colleagues, they actually recommended surgery within 24 hours of injury in this paper. In that, that was for all levels, so they suggested early surgery less than 24 hours for traumatic central cord syndrome and essentially all other levels of injury as well, cervical, thoracic and even lumbar. The quality of evidence was low and weak, however, there's been an increasing number of studies to back this up in recent years. So given the fact that this is the ongoing guidelines for the timing of surgery after SCI, there's been, there's still a lot of open questions about that. And one question is, there's a lot of variability in the extant literature, and our goal is to try to reduce that. So on the table on the left, I listed all the studies that both favor early surgery in the left-hand column and those that do not favor early surgery in the right-hand column. Importantly, the studies in yellow I've highlighted came out after the 2017 guidelines. So what I want to try to highlight is, even though there's these guidelines that surgery within 24 hours is actually, you know, best practice, there's still a lot of variability out there in the literature about is this the best thing to do. Another open question is identifying the optimal time window for early surgery. So by way of background, we had a study in 2019 that looked at not just early surgery less than 24 hours, but looking at early surgery, subdividing it into a very early window or ultra early, less than 12 hours, and a early window from 12 to 24 and a late time window. What we found was that there was increased, essentially AIS conversion from admission to discharge for ultra early surgery, but not for early late or combined ultra early and early. So the idea is that there's a critical window that you have to go to surgery by in order to achieve the benefits of early surgery. That was also found in another study in 2019 in internal neurosurgery as well, where they verified that in a prospective database, again, showing all the black lines there, that there's this ultra early time window that all the benefit of early surgery is contained in. But that still needs to be worked out. And then finally, another question is what is a complete injury? So there's more and more papers coming out about looking at Asia A or complete patients who go to surgery early and then finding that a high percentage from 50 to 80% of patients with Asia A convert to a higher Asia grade, at least a B, and potentially a C or higher. And while that traditionally wasn't seen to be a good outcome, now that with the advent of spinal cord stimulation to recover motor function in patients with even a little bit of function, like an Asia B, that's actually a very big deal. So this complete versus incomplete injury is a major open question and a research objective. So what we wanted to do is address each of these questions. And in doing that, we used the TRAC-SCI database. So the TRAC-SCI stands for Transforming Research and Clinical Knowledge in Spinal Cord Injury, TRAC-SCI. It's a multi-center perspective data registry, contains highly granular, 20,000 variables because of the timing and a lot of the OR and ICU variables are all recorded, and data collection began in June 2016. The inclusion criteria for this study, injury on or before July 2018, so we have at least a 12-month follow-up. Injury treated with surgery, so these are all surgical lesions, has to be a cervical injury itself. And the patient had to survive at least the initial injury, at least until discharge, and then patient was able to participate in a motor exam throughout the hospital stay. For statistics, we're looking at, we're going to separate people into an ultra-early group, less than 12 hours, an early group, 12 to 24 hours, and a late group, greater than 24 hours, and then look at different combined outcomes in terms of bilateral low extremity outcome for motor improvement in each of those groups. In the table on the right, I've listed some basic categorizations of the patients in our database, so looking at them in the AO spine, injury classification, and also the basic score, so that refers to the level of T2 edema on an axial MRI, and so we can see there's fairly well-represented in our database. And then also the type of surgical intervention that each patient received in terms of an anterior-only, posterior-only, or anterior-posterior. So in terms of the results, so this first result was just looking at the change in motor scores for these patients based upon the timing of surgery from admission to discharge, and essentially we found that ultra-early surgery correlates with increased motor outcomes in the immediate recovery period, so this is all immediately after surgery and for the next 7 to 10 days. So 37 total patients were in this analysis, and there was an overall statistical significant increase for ultra-early compared to late surgery, and also that the ANOVA for the whole significance was also significant. And then the early time window, again, all of the concentration of that early time window of ultra-early was in the first 12 hours. So this largely recapitulated our initial retrospective data in a prospective database. For the second results, we wanted to look at follow-ups. So we focused on 12-month follow-up, and what we showed are showing our motor score improvement for every group, and one limitation of this data that we can talk about is for our institution is in a county hospital. We have very limited data. There was only 17 patients out of the entire initial data set that actually showed up for the 12-month follow-up. But even still, even though there wasn't an ultra-early versus early comparison, I think the variability was too high and the end was a little too small, when we compared the less than 24 hours to the late, there was a trend of PS.08 that there was an improvement in motor score recovery at 12-month follow-up for the early less than 24-hour group. And then finally, when we do look at that 12-month follow-up too, when we look at the percentage of people who converted to a higher grade from a lower grade of AIS improvement, we can see that the total early group, less than 24 hours compared to the late, converted to a higher grade at almost 75 percent compared to 25 percent in the late group. And importantly, all the patients with an ASIA-A were taken within that 24-hour time window, and all of them converted to a higher AIS grade. So the conclusions. Number one, I think the goal was to reduce the variability in the existing literature. So again, there's this idea that early surgery, less than 24 hours, is associated with increased motor recovery, and that we added to the literature here by using perspective data and suggesting, again, consistent with this less than 24-hour time window. And I wanted to revisit that table that we looked at in the beginning. And specifically, if we look at this table and we take out all the studies that don't define early surgery by less than 24 hours, that essentially takes out all those studies as well. And now, instead of looking at all studies equally, we weight all the studies by which ones are perspective versus we'll take out the retrospective, what we find is we basically perform that filter, all studies that have prospectively collected data that define early surgery less than 24 hours have an outcome that favors early surgery versus not. So even though the literature may seem like there's equipoise, actually it's very consistent now with the current study as well, early surgery works. Two, we wanted to identify an optimal window for surgery. So here we found that we again found that ultra-early time window, less than 12 hours, there's something special about that, especially in that immediate post-operative recovery period. People are doing better from admission to discharge. And what we need to do is collect more data in a perspective fashion to see what the effect of this immediate recovery has on long-term outcomes, specifically, is that going to hold true for 12 months? We need to increase our perspective database in order to address that. And then finally, three, what is a complete injury? So we found that patients in the early group had a high rate of conversion, so four out of four patients approved to a higher grade for AASA. And really, we're arguing that AASA grades should not influence surgical decision because ultimately when you look at something like the TLIC score, it's just not possible to, at that early time window, to say who's complete and who's incomplete because so many people who are complete at 12 hours after injury have a spinal shock or the exam is just not reliable that we really argue and what we do in our SFGH is we don't include incomplete or incomplete and everyone with an SCI is just treated as a parenchymal injury and is taken to surgery as soon as they can. So I'd like to acknowledge that my mentor, Dr. Sanjay Dahl, also Dr. Jeff Manley, Michael Huang, Feroz Taripour, all the TREC-SCI team, and everyone at SFGH Basic, the AANS, UCSF Neurosurgery for this opportunity to talk and the references are here. Thank you so much.

early surgery

cervical spinal cord injury

benefits

timing for surgery

TRAC-SCI database