- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi 74800, Pakistan
Syed Ather Enam
Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi 74800, Pakistan
DOI:10.4103/2152-7806.90027Copyright: © 2011 Shamim MS. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Shamim MS, Ali SF, Enam SA. Non-operative management is superior to surgical stabilization in spine injury patients with complete neurological deficits: A perspective study from a developing world country, Pakistan. Surg Neurol Int 19-Nov-2011;2:166
How to cite this URL: Shamim MS, Ali SF, Enam SA. Non-operative management is superior to surgical stabilization in spine injury patients with complete neurological deficits: A perspective study from a developing world country, Pakistan. Surg Neurol Int 19-Nov-2011;2:166. Available from: http://sni.wpengine.com/surgicalint_articles/non-operative-management-is-superior-to-surgical-stabilization-in-spine-injury-patients-with-complete-neurological-deficits-a-perspective-study-from-a-developing-world-country-pakistan/
Background:Surgical stabilization of injured spine in patients with complete spinal cord injury is a common practice despite the lack of strong evidence supporting it. The aim of this study is to compare clinical outcomes and cost-effectiveness of surgical stabilization versus conservative management of spinal injury in patients with complete deficits, essentially from a developing country's point of view.
Methods:A detailed analysis of patients with traumatic spine injury and complete deficits admitted at the Aga Khan University Hospital, Pakistan, from January 2004 till January 2010 was carried out. All patients presenting within 14 days of injury were divided in two groups, those who underwent stabilization procedures and those who were managed non-operatively. The two groups were compared with the endpoints being time to rehabilitation, length of hospital stay, 30 day morbidity/mortality, cost of treatment, and status at follow up.
Results:Fifty-four patients fulfilled the inclusion criteria and half of these were operated. On comparing endpoints, patients in the operative group took longer time to rehabilitation (P-value = 0.002); had longer hospital stay (P-value = 0.006) which included longer length of stay in special care unit (P-value = 0.002) as well as intensive care unit (P-value = 0.004); and were associated with more complications, especially those related to infections (P-value = 0.002). The mean cost of treatment was also significantly higher in the operative group (USD 6,500) as compared to non-operative group (USD 1490) (P-value
Conclusion:We recommend that patients with complete SCI should be managed non-operatively with a provision of surgery only if their rehabilitation is impeded due to pain or deformity.
Complete spinal cord injury or complete deficits following spine injury are irreversible.[
We performed retrospective review of charts and departmental inpatient records from January 2004 to January 2008 and then onwards prospectively till January 2010. All patients admitted in the Aga Khan University Hospital, Pakistan, with “complete injury”, i.e. patients with either complete SCI or complete deficits following traumatic spine injury presenting within 14 days of injury were included. Complete SCI was defined as patients having no motor or sensory function below the neurological level, no preserved function in sacral segments S4-S5 (ASIA A),[
We received a total of 294 patients with some form of spine injury over the 6-year study period but only 62 of these patients had complete injuries. Of these 62 patients, a further 8 were excluded, 3 due to delayed presentation, 3 due to severity of associated injuries and 2 that left the hospital against medical advice. The total number of patients included in our study was therefore 54, of which 34 (63 %) were enrolled prospectively. There were 42 male and 12 female patients and the mean age of patients was 34 years which was comparable in the two groups (range 16-72). The mean time from injury to presentation was 53.4 h although 17 patients presented within 12 h of injury. Twenty-four (44%) patients were administered steroids on presentation, as per guidelines based on NASCIS trials, but continued inconsistently.[
Twenty-seven patients underwent stabilization procedures and an equal number were managed without surgery; the demographic variables of the two groups including revised trauma score (RTS) and abbreviated injury scores (AIS) were comparable. Anterior decompression and fusion was the most common surgical procedure performed in 10 patients; the mean time from presentation to surgical stabilization was 6.8 days (3 h to 30 days); the mean duration of surgery was 142 min (120–360 min); the mean intra-operative blood transfusion was less than one unit of packed cell and there were no intra-operative or immediate post-operative complications; the mean time from presentation to rehabilitation was 5 days and the mean length of hospital stay was 17 days for all patients. The group wise details are presented in Tables
Surgical stabilization of patients with complete SCI is a common procedure in most spine centers of the world. Several authors have argued for a non-operative management of these patients but spine surgeons around the world continue to offer surgical stabilization on the basis of “perceived” advantages, such as early re-habilitation, shorter hospital stay, and prevention of progressive spine deformity.[
Indications for surgical stabilization remain subjective.[
Much has been published in the debate for and against stabilization in spinal cord injuries.[
We have shown that managing these patients without surgery leads not only to a significant reduction in complications, mortality, time to rehabilitation, cost, and hospital stay, but also better outcomes at 9-month follow up. Our conclusions have global implication but they imply even more to under developed countries with limited resources available to patients. In under-developed countries, cost of instrumentation is tremendous, compared to per capita income, infection rates are high, rehabilitation centers are few, and follow up is poor.[
There are a few limitations in our study. The follow up of our patients is inadequate as only 21 of 49 patients discharged alive could be followed for a mean follow up of 9 months. Published reports from a different region of our country also show poor follow up (4-6 weeks) of SCI patients.[
We noticed several demographic differences in our patients. It has been suggested that whereas RTA are the leading cause of SCI in developed nations, in developing countries fall is a significant cause too, a pattern that was also observed in our study.[
A similar case study presented itself following the earthquake in Pakistan in 2005 when a large number of spinal cord injuries, with little resources and lack of proper surgical facilities in the area, forced surgeons to test non-operative management to its fullest. Preliminary data from the study supports our findings of higher rates of complications in patients who underwent surgery.[
Our analysis shows that spinal injury patients with complete deficits who underwent stabilization procedures took longer time for rehabilitation, had longer hospital stay including longer length of stay in intensive care unit and special care unit and were associated with more complications, especially those related to infections. Surgical stabilization was associated with persistent back pain on follow ups. The cost of treatment was also significantly high in the operative group. We recommend that patients with complete SCI should be managed non-operatively with a provision of surgery only if they remain symptomatic.
Publication of this manuscript has been possible by an educational grant from
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