The efficacy of surgical decompression before 24 hours versus 24 to 72 hours in patients with spinal cord injury from T1 to L1 – with specific consideration on ethics: a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>There is no clear evidence that early decompression following spinal cord injury (SCI) improves neurologic outcome. Such information must be obtained from randomized controlled trials (RCTs). To date no large scale RCT has been performed evaluating the timing of surgical decompression in the setting of thoracolumbar spinal cord injury. A concern for many is the ethical dilemma that a delay in surgery may adversely effect neurologic recovery although this has never been conclusively proven. The purpose of this study is to compare the efficacy of early (before 24 hours) verse late (24–72 hours) surgical decompression in terms of neurological improvement in the setting of traumatic thoracolumbar spinal cord injury in a randomized format by independent, trained and blinded examiners.</p> <p>Methods</p> <p>In this prospective, randomized clinical trial, 328 selected spinal cord injury patients with traumatic thoracolumbar spinal cord injury are to be randomly assigned to: 1) early surgery (before 24 hours); or 2) late surgery (24–72 hours). A rapid response team and set up is prepared to assist the early treatment for the early decompressive group. Supportive care, i.e. pressure support, immobilization, will be provided on admission to the late decompression group. Patients will be followed for at least 12 months posttrauma.</p> <p>Discussion</p> <p>This study will hopefully assist in contributing to the question of the efficacy of the timing of surgery in traumatic thoracolumbar SCI.</p> <p>Trial Registration</p> <p><b>RCT registration number: ISRCTN61263382</b></p

Acute subdural hematoma and diffuse axonal injury in fatal road traffic accident victims: a clinico-pathological study of 15 patients Hematoma subdural agudo e lesão axonal difusa em vítimas fatais de acidente de trânsito: estudo clínico-patológico de 15 pacientes

OBJECTIVE: Although acute subdural hematoma (ASDH) and diffuse axonal injury (DAI) are commonly associated in victims of head injury due to road traffic accidents, there are only two clinico-pathological studies of this association. We report a clinical and pathological study of 15 patients with ASDH associated with DAI. METHOD: The patients were victims of road traffic accidents and were randomly chosen. The state of consciousness on hospital admission was evaluated by the Glasgow coma scale. For the identification of axons the histological sections of the brain were stained with anti-neurofilament proteins. RESULTS: Twelve of the 15 patients were admitted to hospital in a state of coma; in three patients, the level of consciousness was not evaluated, as they died before hospital admission. CONCLUSION: The poorer prognosis in patients with ASDH who lapse into coma immediately after sustaining a head injury, as described by several authors, can be explained by the almost constant association between ASDH and DAI in victims of fatal road traffic accidents.<br>OBJETIVO: Embora o hematoma subdural agudo (HSDA) e a lesão axonal difusa (LAD) estejam frequentemente associados em vítimas de trauma crânio-encefálico causado por acidentes de trânsito, há somente dois estudos clínico-patológicos sobre esta associação. Relatamos o estudo clínico-patológico de 15 pacientes com HSDA associado com LAD. MÉTODO: Os pacientes, vítimas de acidentes de trânsito, foram selecionados aleatoriamente. O estado de consciência à admissão hospitalar foi avaliado pela escala de coma de Glasgow. Para a identificação dos axônios, os cortes histológicos do cérebro foram corados com antisoro anti-proteínas do neurofilamento. RESULTADOS: Doze dos 15 pacientes foram admitidos no hospital em estado de coma; em três pacientes, o nível de consciência não foi avaliado, pois eles faleceram antes da admissão hospitalar. CONCLUSÃO: O pior prognóstico em pacientes com HSDA que apresentam coma imediatamente após serem admitidos por trauma crânio-encefálico, como descrito por vários autores, pode ser explicado pela quase que constante associação entre HSDA e LAD em vítimas fatais de acidentes de trânsito