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Spinal Cord Injury: Progress, Promise, and Priorities
a specialized trauma center averaged 6.2 hours. Also, the quality of the care administered during transport has improved. Before 1968, many deaths took place in transit as a result of inadequate respiratory or cardiovascular support. Current treatment guidelines call for rapid transport to the closest facility with the capacity to evaluate and treat spinal cord injuries (AANS/CNS, 2002c).
Despite the progress in care at the scene of the injury, there are as yet no demonstrably effective pharmacological therapies that can be administered at the scene or during transport. Further attention needs to be given to the development of acute-care therapeutic interventions and to evaluation of other emergency response efforts that might improve patient outcomes, such as methods to relieve compression of the spinal cord and prevent further cell death, edema, and ischemia.
Decompression of the Spinal Cord
Decompression of the spinal cord, if it is performed during the appropriate time window, may provide a benefit to individuals with spinal cord injuries. In many patients, surgery is performed soon after the injury to remove the tissue debris, bone, disc, and fluid that compress the spinal cord. The goal is to alleviate pressure and to improve the circulation of blood and cerebrospinal fluid, particularly for those with central cervical spinal cord injuries (Dobkin and Havton, 2004). Yet there are many unknowns about the value and timing of this procedure. Studies of decompression in rodents after a spinal cord injury demonstrate that the longer compression of the spinal cord exists, the worse the prognosis for neurological recovery (Dimar et al., 1999).
A meta-analysis found that although decompression clearly improves neurological recovery in animal models, the findings for humans are less impressive (Fehlings et al., 2001). Studies favoring decompression have mostly been case studies, which are less robust types of analyses than randomized controlled trials. No prospective clinical trials of the benefits and risks of decompression have been conducted. Furthermore, in the studies that have already been completed, the timing of surgery was not uniform, so the optimal timing remains unknown. Nevertheless, the best indication about timing comes from a large case series that found that the greatest benefits were obtained when decompression was performed within 6 hours of the injury (Aebi et al., 1986). Some evidence, on the other hand, indicates that decompression of the spinal cord may be harmful and is best avoided, as long as the individuals are provided with nonsurgical therapies (Fehlings et al., 2001). Weighing the evidence as a whole, two professional groups adopted the position that decompression does not constitute the standard of care but should remain an option (Silber and Vaccaro, 2001;