An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery

Michael G. Fehlings, Lindsay A. Tetreault, Laureen Hachem, Nathan Evaniew, Mario Ganau, Stephen L. McKenna, Chris J. Neal, Narihito Nagoshi, Vafa Rahimi-Movaghar, Bizhan Aarabi, Christoph P. Hofstetter, Valerie ter Wengel, Hiroaki Nakashima, Allan R. Martin, Steven Kirshblum, Ricardo Rodrigues Pinto, Rex A.W. Marco, Jefferson R. Wilson, David E. Kahn, Virginia F.J. NewcombeCarl M. Zipser, Sam Douglas, Shekar N. Kurpad, Yi Lu, Rajiv Saigal, Uzma Samadani, Paul M. Arnold, Gregory W.J. Hawryluk, Andrea C. Skelly, Brian K. Kwon

Research output: Contribution to journalArticlepeer-review


Study Design: Clinical practice guideline development. Objectives: Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that “early” surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI). Methods: A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the “evidence-to-recommendation” framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. Results: The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence. Conclusions: It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.

Original languageEnglish (US)
Pages (from-to)174S-186S
JournalGlobal Spine Journal
Issue number3_suppl
StatePublished - Mar 2024


  • clinical practice guideline
  • decompression
  • early surgery
  • neurological outcomes
  • spinal cord injury
  • timing of surgery
  • trauma

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine
  • Clinical Neurology


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