Dr. Young, should surgeons operate immediately?

[manouli]

Dr. Young, should surgeons operate immediately, within hours of the severe spinal injury, to try to limit the damage to the spinal cord and surrounding tissues? Or won't it make a difference in how a patient ultimately fares? When I got hurt, I did meet a lady and she was paralyzed too from an accident, but doctors did not operate her at all, but they operated me right way. Thank you for your thoughts.

manouli.

[Kratos]

ahoy, i'm t 5complete and the doctors did not operate me, why i dont know...

[teesieme]

If I had known then what I do now, since my son was "stable" with the choices given that very night or the next morning, I would've chose that night now... but it was Memorial Sunday evening, sadly a busy emergency weekend and the surgeon/team was exhausted. I was also fearful of losing my kid on the table... I think as wonderful as his surgeon was (is) he and his team agreed *nothing* from the chest down in their own way~ he started surprizing them with sensation return two days later. I will always question my choice but I didn't know, thinking stabilized meant his spinal cord, surgery for his backbone~ sigh.

It is I believe a sooner the better to relieve compression and limit damage as time counts.

[giambjj]

Most surgeons give steriods and wait for the swelling to go down, before they operate. If it is neck injury they use traction to stabalize the spine before surgery.


JJG

[kenf]

i waited a year to decompress my spine at T4. couldn't have that vert pushing on my cord the rest of my days. the nero said he saw no damage at all , not even a cut in the duramater. found this site read up on decompressing and went for it. some of the stuff i read said you could get some return 2 years after. they would of done it will i was in a induced coma for 4 weeks. who knows what would of happen.

[Wise Young]

Originally Posted by manouli

Dr. Young, should surgeons operate immediately, within hours of the severe spinal injury, to try to limit the damage to the spinal cord and surrounding tissues? Or won't it make a difference in how a patient ultimately fares? When I got hurt, I did meet a lady and she was paralyzed too from an accident, but doctors did not operate her at all, but they operated me right way. Thank you for your thoughts.

manouli.

Manouli,

The surgical community is split concerning this issue. In the 1950-1960's, surgeons thought that surgery would not be beneficial. In fact, this was what was advocated in Stokes-Mandeville for many decades and the doctors simply refused to operate, even to stabilize the spinal column.

In the 1970's and 1980s, due to recognition that some patients with incomplete spinal cord injuries recoverd substantially, most doctors adopted the view that the spinal cord should be decompressed by straightening the spine as soon as possible. However, many surgeons still felt that it was not necessary to decompress the spinal cord until 48 hours or longer, that it would
restore function.

In the 1990's, the confluence of several developments changed the field. First, at the beginning of the 1990's, the National Acute Spinal Cord Injury Study showed that methylprednisolone had to be given within 8 hours after injury to be effective, effectively changing the time-scale for intervention in acute spinal cord injury. Second, the advent of anterior and posterior plates fro the cervical allowed rapid and effective straightening and stabilization of the spinal column. More important, the stabilization of the spinal column allowed rapid mobilization of patients after the surgery, so that they could be discharged from the acute care ward to rehabilitation within a week, significantly reducing the length of stay and therefore the profit to the hospital. Third, Hank Bohlman at Case Western Reserve University published several influential papers showing that decompression of the spinal as late as 3 years after injury was not only safe but could still restore some function. So, today, most neurosurgeon and orthopedic surgeons will try to operate within 24 hours, to straighten out the spinal column and stabilize it.

The timing of the surgery is still controversial. Some surgeons believe that it is necessary to decompress the spinal cord as soon as possible, in 3-4 hours. However, others think that "rapid" decompression means doing so within 24 hours. Both may be too slow. After all, if one were to deprive part of the bran of blood flow for 3-4 hours, one would expect that part of the brain to die. Many of the older neurosurgeons who trained in the 1970's and 1980's will operate at 24 hours or later. They are also less likely to operate and to delay operation on somebody with a "complete" spinal cord injury.

I tried several times in the 1980's to organize a clinical trial to assess this question in the 1980's and 1990's. It was very difficult to get funding for such a trial in the 1980's. In the 1990's, the positions of surgeons were sufficiently entrenched that it was not possible to convince surgeons to randomize to early decompression (<8 hours), late decompression (>8 hours), or no decompression. So, today, the question is unresolved.

Wise.

[spidergirl]

Originally Posted by Wise Young

The timing of the surgery is still controversial. Some surgeons believe that it is necessary to decompress the spinal cord as soon as possible, in 3-4 hours. However, others think that "rapid" decompression means doing so within 24 hours. Both may be too slow. After all, if one were to deprive part of the bran of blood flow for 3-4 hours, one would expect that part of the brain to die. Many of the older neurosurgeons who trained in the 1970's and 1980's will operate at 24 hours or later. They are also less likely to operate and to delay operation on somebody with a "complete" spinal cord injury.




Wise.

I had my cord decompressed and rods put in my back within hours after my injury. Oddly enough, my injury happened 2 blocks from my hospital. My surgeon told my mother " I did the best job I can possibly do, now it's up to your daughter" They can leave me with no scar ( bc if dissolving inside stitching) but leave me with a broken nerve.

My mom had a surgery done on her back 30 years ago and she still has a scar. I have zero scar. You can't even tell my back was opened.

Also, how in the world can anyone know within 24 hours whether your an "incomplete" or "complete"? Very weird.

[manouli]

Dr. Young, thank you very much for your generous time to answer everybody's questions, I know how precious your time is with your schedule. Neither the lady or I recover walking, although I was luckier than her because of the level of my injury C-7-C8, I can move my hands, but she could not. I spend 6 months in rehab, she left after 1 month because doctors said they coul not help her recover so she thought it was waisting her time. I met so many people with paralysis is unreal some time.

manouli.

[manouli]

Originally Posted by spidergirl

I had my cord decompressed and rods put in my back within hours after my injury. Oddly enough, my injury happened 2 blocks from my hospital. My surgeon told my mother " I did the best job I can possibly do, now it's up to your daughter" They can leave me with no scar ( bc if dissolving inside stitching) but leave me with a broken nerve.

My mom had a surgery done on her back 30 years ago and she still has a scar. I have zero scar. You can't even tell my back was opened.

Also, how in the world can anyone know within 24 hours whether your an "incomplete" or "complete"? Very weird.

spidergirl, that's a great question! Really how do they know if you are paralyzed complete or forever. I was out like in coma stage and when I woke up, they told me that I will be like this for the rest of my life. Maybe from X-rays?

manouli

[Wise Young]

Originally Posted by spidergirl

I had my cord decompressed and rods put in my back within hours after my injury. Oddly enough, my injury happened 2 blocks from my hospital. My surgeon told my mother " I did the best job I can possibly do, now it's up to your daughter" They can leave me with no scar ( bc if dissolving inside stitching) but leave me with a broken nerve.

My mom had a surgery done on her back 30 years ago and she still has a scar. I have zero scar. You can't even tell my back was opened.

Also, how in the world can anyone know within 24 hours whether your an "incomplete" or "complete"? Very weird.

They must be very good with the cutting and suturing of the surgical wound to leave "zero scar". The definition of "complete" or "incomplete" spinal cord injury is made by neurological examination. I personally would like to abolish the term "complete" spinal cord injury. It is not absolutely predictive. In my experience and those of others, about 17% of the people with ASIA A (complete) at 24 hours recover to become ASIA B or C (most C), particularly if they have received methylprednisolone within 3 hours. Only rarely do people with ASIA A, however, become ASIA C, at least in the United States.

I am not free yet to talk about the new findings that I have seen in China (because it is not my data and the doctors are trying to publish the data) but I think that decompressive surgery may be more beneficial than most American surgeons realize. I have now seen a number of patients go from ASIA A to ASIA D here in China.

Wise.