Introduction
The concept of “time is spine” underscores the importance of early (within 24 hours) or ultra-early (within 12 hours) surgical decompression following spinal cord injury (SCI) to improve neurological recovery. This review explores recent evidence on the timing of decompression and hemodynamic management in acute SCI. While early intervention shows potential benefits, its effectiveness can vary depending on injury severity, patient comorbidities, and healthcare system capabilities. Recent studies question the added value of ultra-early decompression, suggesting that previous findings may have overstated its long-term benefits.
Given the variability in outcomes and limitations of existing studies, current recommendations emphasize a patient-specific approach. Timing should be tailored to each case, considering individual health factors and institutional resources. New technologies such as spinal cord pressure monitoring, intraoperative ultrasound, and advanced imaging are enhancing decision-making and intervention strategies. Overall, a multidisciplinary, personalized approach is essential, and further research is needed to determine optimal intervention timing and improve recovery outcomes in SCI patients.
THE ROLE OF THE INTENSIVIST IN SPINAL CORD INJURY MANAGEMENT
Intensivists represent one of the first lines of healthcare practitioners to assess SCI patients, and their early actions can significantly influence recovery outcomes. The intensivist’s role often involves:
- Maintenance of spinal stabilization: Immediate stabilization of the airway, breathing, and circulation, along with spinal stabilization, is crucial to prevent further mechanical damage and reduce the risk of exacerbating spinal injuries during patient transport and positioning.
- Neurological assessment: Standardized tools such as the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) published by the American Spinal Injury Association are used to assess the severity of the injury and monitor for any changes in the patient’s neurological status. Regular assessments are critical for tracking progress and determining surgical or other interventional needs.
- Hemodynamic management: Hypotension is common in SCI due to neurogenic shock or hypovolemia and can worsen secondary injury by reducing spinal cord perfusion. Ensuring adequate optimal spinal cord perfusion through vigilant hemodynamic management is ideal to prevent further ischemic injury to the spinal cord.
- Respiratory management: Supporting respiratory function, especially in cervical SCIs, which may impair ventilation. Early mechanical ventilation, especially in injuries above the C3 level, and proactive pulmonary care can reduce the risk of complications like pneumonia.
- Multidisciplinary coordination: The intensivist plays an integral role in coordinating multidisciplinary are with neurosurgeons, orthopedic surgeons, and trauma teams. This collaboration is critical for determining the timing of decompression surgery and ensuring that all aspects of the patient’s care are integrated for the best possible outcome.
Timing of Surgical Decompression: Why ‘Time is Spine’ Matters
Neurological recovery in SCI is influenced by injury severity and the timing of surgical intervention. Decompression aims to relieve spinal cord pressure, restore alignment, and reduce secondary damage like ischemia and inflammation. While the exact benefit of early decompression remains debated, earlier surgery may support quicker mobilization, reduce complications, and shorten ICU stays.
Early vs. Ultra-Early Decompression
Early decompression (within 24 hours) has been linked to better neurological outcomes in some studies, such as STASCIS, though definitive evidence is lacking due to methodological limitations. Ultra-early decompression (within 12 hours) was evaluated in the SCI-POEM study, which found no significant benefit at 12 months. Current guidelines recommend surgery within 24 hours when feasible, but leading neurosurgical bodies caution that the existing evidence is inconsistent. Therefore, surgical timing should be individualized based on injury type, patient condition, and systemic factors.
LIMITATIONS OF ULTRA-EARLY AND EARLY DECOMPRESSION
Several factors suggest that early or ultra-early decompression may have limited utility in the management of SCI. These factors can be patient-specific, injury-specific, or related to broader healthcare system capabilities. Factors such as those listed below may impact the evaluation of the potential benefits on the timing of surgical intervention:
- Severity of initial injury: The extent of the primary mechanical damage to the spinal cord can be a determinant of outcome. In cases of complete transection or severe contusion with extensive neurological deficit, the potential for recovery may be limited regardless of the timing of decompression.
- Presence of polytrauma: Patients with multiple injuries may not be stable enough for immediate surgery. The need to prioritize life-saving interventions over decompressive surgery can necessitate the delay of surgical intervention.
- Preexisting comorbidities: Patients with significant comorbidities may not tolerate early surgery well, and the risks associated with anesthesia and the surgical procedure itself may outweigh the potential benefits of early decompression.
- Presence of confounding factors: Patients may present with confounding factors such as intoxication from drugs or alcohol, limiting the initial exam and potentially overestimating the benefits of early surgery.
- Spinal cord edema: Extensive spinal cord swelling can make early surgical intervention of only osseous decompression insufficient. In these cases, a more extensive decompression and/or durotomy with duraplasty may be required.
- Spinal shock: The presence of spinal shock, characterized by a temporary loss of spinal reflex activity below the level of injury, can make it difficult to accurately assess the degree of SCI and the potential benefits of early decompression.
- Availability of surgical expertise and resources: The lack of immediate access to a specialized spine surgery team and the necessary infrastructure can preclude ultra-early or early decompression.
- Quality of evidence: There is no prospective class I evidence that supports a recommendation for the timing of surgical intervention.
- Molecular and genetic factors: Emerging research suggests that individual molecular and genetic factors may influence the response to injury and recovery potential, potentially impacting the utility of early decompression.
- Logistical and systemic delays: Delays in diagnosis, transfer to a specialized center, obtaining necessary imaging studies or obtaining expert personnel can impact the timing of decompression beyond the early or ultra-early window.
- Economic and social considerations: Financial constraints, lack of insurance coverage, or social circumstances may delay the timing of surgery.
In summary, while early and ultra-early decompression have been associated with improved outcomes in some studies, individual patient factors, injury characteristics, and systemic issues must be carefully considered when determining the optimal timing for surgical intervention in SCI.
BENEFITS OF EARLY DECOMPRESSION
Conversely, several factors suggest that early or ultra-early decompression may be beneficial for patients with SCI. These factors are based on the understanding of SCI pathophysiology and the potential for improved outcomes with timely intervention:
- Mechanism of injury: In cases where SCI is primarily due to ongoing compression from bone fragments, herniated discs, or hematoma, early or ultra-early decompression can relieve mechanical pressure and may limit secondary injury.
- Incomplete SCI: Patients with incomplete SCI, where some sensory or motor function is preserved below the level of injury, may benefit more from early decompression for recovery of function and prevention of further deterioration.
- Rapidly worsening neurological status: If a patient’s neurological status is deteriorating quickly, early decompression may halt or reverse this decline.
- Spinal cord edema without severe compression: If imaging suggests that spinal cord edema is present without severe compression, decompression may prevent further ischemic damage by improving vascular perfusion.
- Availability of surgical expertise and infrastructure: Access to a specialized neurosurgical team and the necessary infrastructure for immediate surgery can facilitate early decompression and potentially improve outcomes.
- Evidence of ongoing compression on imaging: MRI, CT myelogram or intraoperative ultrasound showing evidence of ongoing spinal cord compression would provide a rationale for interventions to alleviate pressure.
- Younger age and good health: Younger patients and those in good health may have a better capacity for recovery and tolerate early surgical intervention more effectively.
- Absence of major comorbidities: Patients without significant comorbidities are less likely to experience complications from early surgery and may benefit from early decompression.
- Patient and family preferences: Informed patients or their families who understand the potential benefits and risks may opt for early intervention.
- Systemic inflammatory response: Early decompression may mitigate the systemic inflammatory response that can exacerbate secondary injury.
- Preservation of spinal cord perfusion: Early decompression can help preserve spinal cord blood flow, which is critical for the delivery of oxygen and nutrients, as well as the removal of waste products.
- Reduction in hospital stay and healthcare costs: Early decompression with spinal stabilization may be associated with shorter hospital stays and reduced healthcare costs due to faster recovery and fewer complications.
- Potential for neural plasticity: Early intervention may capitalize on the spinal cord’s plasticity, enhancing the potential for neural circuit reorganization and recovery.
- Alignment and stabilization: Early decompression with spinal stabilization can prevent further mechanical injury and facilitate earlier rehabilitation.
It is important to note that while these factors suggest potential benefits of early or ultra-early decompression, the decision to proceed with surgery must be individualized. The overall clinical context and the patient’s specific circumstances should guide the timing of decompression, with collaboration among neurosurgeons, intensivists, and rehabilitation specialists aimed at optimizing patient outcomes.
Hemodynamic Management of Acute Spinal Cord Injury
Hemodynamic and Cardiovascular Management:
Maintaining spinal cord blood flow is essential to prevent worsening injury. High thoracic and cervical SCI patients often face neurogenic shock, bradycardia, and hypotension, which can reduce spinal cord perfusion and worsen outcomes.
Optimizing Hemodynamic Management:
Mean arterial pressure (MAP) is used as a proxy for spinal cord perfusion, but evidence linking specific MAP targets to neurological recovery is weak. Maintaining MAP between 75–95 mmHg for 3–7 days is suggested, but overuse of vasopressors may cause arrhythmias or worsen spinal cord bleeding. No clear guidelines exist on the best vasopressor choice.
Utility of Monitoring Spinal Cord Perfusion:
Similar to brain injury monitoring, measuring spinal cord perfusion pressure (SCPP)—the difference between MAP and spinal pressures (ITP or ISP)—offers insight into cord perfusion. Techniques like lumbar catheters, intradural probes, MRI, CT myelography, and intraoperative ultrasound help assess and manage cord swelling and compression beyond bony decompression. New interventions like durotomy with duraplasty are under study to relieve pressure and improve outcomes. However, evidence on optimal SCPP targets remains limited.
Conclusion: The Path Forward in Spinal Cord Injury Care
Early or ultra-early decompression guided by the ‘time is spine’ principle holds potential to improve neurological outcomes in SCI, but current evidence is insufficient for universal timing recommendations. Surgical decisions should be personalized based on injury severity, patient factors, and available resources. Optimizing hemodynamic management and respiratory care is vital, with intensivists playing a key role in early management and multidisciplinary coordination. Future progress requires more rigorous research and individualized treatment strategies, combining surgical and neuroprotective approaches.
Source: Sandarage, Ryana; Nashed, Joseph Y.b; Tsai, Eve C.a,c. Time is spine: critical updates for the intensivist. Current Opinion in Critical Care 31(2):p 117-122, April 2025. | DOI: 10.1097/MCC.0000000000001245
