Early Versus Late Surgical Decompression for Acute Spinal Cord Injury: An Individual Patient Data Meta-Analysis of 1548 Patients

INTRODUCTION: We sought to leverage the statistical power derived from pooling 4 high-quality prospective datasets to compare sensorimotor recovery with early (< 24 hr) vs late (≥ 24 hr) surgical decompression for acute traumatic spinal cord injury (SCI). METHODS: Patients with acute SCI who underwent surgical decompression were identified from 4 prospective, multi-center SCI datasets (NACTN, STASCIS, Sygen, and NASCIS III). Patients were dichotomized into early (< 24 hr) and late (≥ 24 hr) surgery groups. The primary end point was change in ASIA motor score (AMS) at 1-yr. Secondary outcomes included AIS grade and change in ASIA light touch and pin prick scores at 1-yr. One-stage meta-analyses for each outcome were performed by hierarchical mixed-effects regression using a stratified intercept to account for clustering of patients within studies. Fixed-effect covariates were specified for baseline score, age, injury mechanism, AIS grade, neurological level, and steroids. The treatment (early vs late surgery) was specified as a random-effect. RESULTS: A total of 1548 patients were eligible. The early surgery group experienced greater improvement than the late surgery group at 1-yr for AMS (MD 4.0, 95% CI 1.7-6.2, P = .001), light touch score (MD 4.6, 95% CI 1.9-7.2, P = .001), and pin prick score (MD 4.2, 95% CI 1.5-6.9, P = .003). Further, on ‘shift analysis', the early surgery group achieved a more favorable distribution of AIS grades at 1-yr compared to the late surgery group (cOR 1.46, 95% CI 1.14-1.87, P = .003). The effect of early surgery was strongest for cervical SCI (P = .003); however, we observed a trend toward improved recovery with early versus late surgery for thoracic SCI as well (MD 5.2, 95% CI -0.8-11.2, P = .088). CONCLUSION: In an individual patient data meta-analysis adjusting for potential confounders, we found early surgery, within 24 hr of injury, to be associated with superior sensorimotor recovery at 1-yr following acute SCI, as compared to late surgery.