Hello, everyone. My name is Ryan Chu, and I am a rising fourth-year medical student at the University of Illinois College of Medicine. Here, I will be presenting our nationwide analysis on the timing of surgery for cervical central cord syndrome, a topic that has been highly debated within the field of neurotrauma. I have no disclosures. Central cord syndrome is the most common incomplete SCI, and it was first described by a guy named Schneider in 1954, who described a type of cervical SCI involving, quote, disproportionately more motor impairment of the upper than of the lower extremities, bladder dysfunction, usually urinary retention, and varying degrees of sensory loss below the level of the lesion. This description still remains relatively accurate to this day. Central cord syndrome is thought to be caused by hyperextension injury of the cervical region superimposed on a preexisting stenosis of the spinal canal itself, either from discogenic processes or degeneration, osteophytes, or a hypertrophied ligament inflatement. You can see here that the contusion that results from such an injury affects the center of the cord, hence the name central cord syndrome. Because the cervical portions of the spinothalamic and cortical spinal tracts, as you can see on the figure, are theoretically located more medially, this explains why there is exacerbated upper extremity symptoms and fewer lower extremity symptoms. Ever since Schneider's initial account in the 1950s and his subsequent patient series, it has been traditionally thought that surgical decompression for central cord patients was actually detrimental to them, since the natural history of this condition was thought to be relatively favorable and self-remediating, and that iatrogenic insults to the cord from surgery and to surrounding structures would hamper this physiologic recovery. However, it is important to note that these statements were made during a time when decompression procedures and spine operations as a whole were very different than they are today and much more morbid. The more prevalent modern controversy in this arena, therefore, is instead among the surgically indicated patients themselves, and the question has now become when to operate on these patients rather than if we should operate on these patients. There has been a lack of a prospective study on the timing of surgery for central cord syndrome patients, and existing retrospective data have almost exclusively been single-centered retrospective chart reviews and analyses. As you can see in this 2015 review from Anderson et al., the studies that are in the literature have vastly different definitions of what it means to have been operated upon early versus late. As you can see from the tables, there are some studies that use 24 hours as a cutoff, some studies that use two days as a cutoff, four days, etc., etc. Thus, the objective of our study is to assess the association of timing of surgical decompression on patient outcomes, disposition, and cost of hospitalization in patients presenting with traumatic cervical central cord syndrome. In this study, we utilized the Nationwide Inpatient Sample, which is the largest all-payer administrative database available for public use in the United States. We identified patients presenting with traumatic central cord syndrome using IC9 diagnosis codes listed here, and then from these patients identified surgical candidates using IC9 procedure codes for decompression of neural elements. The endpoints of the study are inpatient outcomes defined by the NIS. That is, all-cause mortality, discharge disposition, length of stay, and total hospital charges. In order to develop a more objective and systematic way to determine early and late surgery, we plotted time until surgery for all patients in our study cohort and found the median of these to be two days. In essence, this means that half the patients in our cohort have been operated earlier to this time point and half later to this time point. We underwent a propensity score match analysis using logistic regression analysis in order to better account for other baseline factors that may have been confounding influences on our results. As you can see here, it was relatively successful at equalizing the mortality risk and severity of injury between the two groups of patients. Results from our propensity match cohort indicate that earlier intervention was associated with better discharge disposition in terms of the percentage of patients going directly home as opposed to a SNF, intermediate care center, or rehab facility. Early intervention was also associated with a shorter length of stay, but not shorter post-operative length of stay, indicating that the total hospitalization length was determined primarily by the time from admission to surgery. That is, early intervention patients were discharged after a shorter total length of stay simply because they were operated upon earlier and they got to the OR in fewer days. Early intervention was nonetheless associated with decreased cost of care, likely as a result of decreased total length of hospitalization. In summary, this was the largest multicenter study of timing of surgery for central corte syndrome. And as a multicenter study, we likely have more external validity and generalizability compared to existing single center studies. In our study, early surgery appears to result in better inpatient outcomes. There are varying definitions in the literature of early and late, and these are rather arbitrary a lot of the times, poorly justified time points. But here in this study, we utilize a systematic approach for determining this time point using a nationwide median as a benchmark. As far as the limitation of the study is concerned, we conducted a retrospective analysis, which has its own limitations regarding the inability to assess all possible confounders. This was therefore class three evidence, not very much unlike the studies in the existing literature. This was an administrative database through the NIS, which is limited by coding practices in individual institutions. And there were no markers in this database of neurologic injury status, like the ASIA impairment score, upper extremity motor score, or lower extremity motor score, and thus there may have been an element of selection bias within our study groups. These are references that we used in the conduction of this study. Thank you very much for listening to our talk.

cervical central cord syndrome

surgical timing

patient outcomes

early intervention

Nationwide Inpatient Sample