Emergency.

2017; 5 (1): e37

R EVIEW A RTICLE

Early versus Late Decompression for Traumatic Spinal

Cord Injuries; a Systematic Review and Meta-analysis
Mahmoud Yousefifard1,2 , Vafa Rahimi-Movaghar1 , Masoud Baikpour3 , Parisa Ghelichkhani4 , Mostafa
Hosseini5,1,6 ∗ , Ali Moghadas Jafari7 , Heidar Aziznejad8 , Abbas Tafakhori9,10
1. Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.

2. Physiology Research Center and Department of Physiology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran.

3. Department of Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.

4. Department of Intensive Care Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.

5. Pediatric Chronic Kidney Diseases Research Center, Children’s Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran

6. Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

7. Department of Emergency Medicine, School of Medicine, Bushehr University of Medical Sciences, Bushehr, Iran.

8. The Persian Gulf Tropical Medicine Research Center, Bushehr University of Medical Sciences, Bushehr, Iran.

9. Department of Neurology, School of Medicine, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran.

10.Iranian Center of Neurological Research, Tehran University of Medical Sciences, Tehran, Iran.

Received: May 2016; Accepted: Jun 2016; Published online: 11 January 2017

Abstract: Introduction: Despite the vast number of surveys, no consensus has been reached on the optimum timing
of spinal decompression surgery. This systematic review and meta-analysis aimed to compare the effects of
early and late spinal decompression surgery on neurologic improvement and post-surgical complications in
patients with traumatic spinal cord injuries. Methods: Two independent reviewers carried out an extended
search in electronic databases. Data of neurological outcome and post-surgery complication were extracted.
Finally, pooled relative risk (RR) with a 95% confidence interval (CI) was reported for comparing of efficacy
of early and late surgical decompression. Results: Eventually 22 studies were included. The pooled RR was
0.77 (95% CI: 0.68-0.89) for at least one grade neurological improvement, and 0.84 (95% CI: 0.77-0.92) for at
least two grade improvement. Pooled RR for surgical decompression performed within 12 hours after the injury
was 0.26 (95% CI: 0.13-0.52; p<0.001), while it was 0.75 (95% CI: 0.63-0.90; p=0.002) when the procedure was
performed within 24 hours, and 0.93 (95% CI: 0.76-1.14; p=0.48) when it was carried out in the first 72 hours
after the injury. Surgical decompression performed within 24 hours after injury was found to be associated with
significantly lower rates of post-surgical complications (RR=0.77; 95% CI: 0.68-0.86; p<0.001). Conclusion: The
findings of this study indicate that early spinal decompression surgery can improve neurologic recovery and
is associated with less post-surgical complications. The optimum efficacy is observed when the procedure is
performed within 12 hours of the injury.

Keywords: Decompression, Surgical; Early Surgical Decompression; Late Surgery; Injured Spinal Cord.
© Copyright (2017) Shahid Beheshti University of Medical Sciences

Cite this article as: Yousefifard M, Rahimi-Movaghar V, Baikpour M, Ghelichkhani P, Hosseini M, Moghadas Jafari A, Aziznejad H, Tafakhori
A. Early versus late decompression for traumatic spinal cord injuries; a systematic review and meta-analysis. Emergency. 2017; 5(1): e37.

1. Introduction
Spinal decompression surgery is beneficial for decreasing the
∗ Corresponding Author: Mostafa Hosseini; Department of Epidemiology and
probability of post spinal cord injury (SCI) neurological im-
Biostatistics, School of Public Health, Poursina Ave, Tehran, Iran; Tel/Fax:
+982188989125 ; Email: mhossein110@yahoo.com pairments. Findings of experimental and clinical studies
have confirmed that it improves patient outcomes by pre-

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M. Yousefifard et al. 2

venting the activation of secondary injury mechanisms (1, 2.1. Inclusion criteria:
2). However, there is an ongoing controversy regarding the All the clinical trials (class I), controlled prospective cohorts
best time for surgical intervention. Some clinical trials are (class II), case series and retrospective studies (class III) that
indicative of better motor and neurologic recovery with early evaluated and compared the effects of early spinal decom-
surgical decompression compared to late interventions(2, 3), pression surgery with late surgery on outcome of spinal cord
while others have shown otherwise (4), One way to reach injuries were included. Since a meta-analysis published in
a consensus is conducting a systematic review and meta- 2004 had evaluated the articles published before the year
analysis. In this regard, two meta-analyses have been pub- 2000 (6), in this study only studies carried out after that were
lished in 2004 and 2006 (5, 6). In addition, another study has included. Sample population comprised of patients with
been carried out in 2013 to assess different surgical schedules spinal cord injuries without any gender or ethnic restrictions.
in SCIs, but presence of publication bias and considerable Studies were included, in which the neurologic outcome was
heterogeneity has kept the authors from arriving at a reliable assessed based on American Spinal Injury Association (AISA)
conclusion on this matter (7). score, American Spinal Injury Association Impairment Scale
In recent years, a significant number of clinical trials and (AIS), and the Frankel score. Studying patients younger than
cohort studies have compared the efficacies of early and 14 years old and non-traumatic patients, not categorizing
late surgical decompression, which provide a suitable basis subjects into two groups of early and late interventions, us-
for conducting a meta-analysis on human studies. In this ing a temporal cut-off of more than 72 hours for classification
regard, the present study aimed to compare the effects of late of patients, and following the subjects for less than 6 months
and early surgical decompression on motor and neurologic (for assessing neurological outcome) were regarded as exclu-
recovery of SCI patients through a systematic review and sion criteria. In addition, studies that assessed post-surgical
meta-analysis. complication were included.

2.2. Quality Assessment and Data Extraction:

2. Methods The search results were combined and duplicate studies were
To find the maximum number of related articles, an extended removed using the EndNote software (version X5, Thom-
search was carried out in databases of Medline (via PubMed), son Reuters, 2011). The methodology of the studies was as-
EMBASE (via OvidSP), CENTRAL, SCOPUS, Web of Science sessed and controlled by two independent researchers and
(BIOSIS), and ProQuest from January 2000 to the end of Oc- the summaries of extracted sources were recorded in data ex-
tober 2015. Search strategy was based on combining terms traction forms. In cases of disagreement, a third reviewer
related to “surgical decompression” with keywords related to evaluated the findings and the inconsistency was resolved
“spinal cord injuries” (Panel 1). The keywords were selected through discussion. Data collection was done blinded to the
using Mesh and EMTREE through manual search in the titles authors, journals, institutions and departments of the arti-
and abstracts of related articles and eventually by consulting cles. The findings of the systematic search were recorded in
experts. a checklist designed based on the PRISMA statement guide-
In searching PubMed interface, the archived articles in lines (8). Study design, characteristics of sample populations
PubMed Central database were also included. Other than the (age, gender, mechanism of SCI), type of injury (complete,
mentioned systematic search, manual search was performed incomplete), etiology (motor-vehicle accidents, falling, etc.),
in Google scholar and Google search engine. The authors location of injury (cervical, thoracic, lumbar), sample size,
of related articles were also contacted via email and were temporal cut-off point used for classification of the patients,
asked to provide us with any unpublished data, unrecorded final outcome (neurologic outcome, post-surgical complica-
information or unpublished dissertations they had. In cases tions), and possible biases were extracted. In cases of dupli-
where data were not available online, the authors were con- cate results, the study with the greater sample size was in-
tacted. If no response was received, a reminder was sent a cluded. When the results were presented at different times,
week later. If the author did not respond again, other authors the findings of the last follow up were included. In cases that
of the article were asked for the data through social networks results were presented as charts, the data extraction method
such as ResearchGate and LinkedIn. Bibliographies of rele- suggested by Sistrom and Mergo was utilized (9).
vant studies were also hand-searched to find further articles
2.3. Quality assessment
or unpublished data.
The quality of the included studies was assessed based on the
guideline proposed by the Agency for Healthcare Research
and Quality’s Methods Guide for Effectiveness and Compar-

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3 Emergency. 2017; 5 (1): e37

Panel 1: Keywords used for search in EMBASE and MEDLINE databases

Database Search terms

Medline (PubMed) (“Decompression, Surgical”[Mesh] OR “Surgical Decompression*”[tiab] OR "Early versus late surgical decom-
pression”[tiab] OR "early surgical decompression"[tiab] OR "late surgical decompression"[tiab] OR "delay* de-
compression"[tiab] OR “immediate decompression’[tiab] OR “Delay* treatment"[tiab] OR "Early treatment"[tiab]
OR “Late surgery”[tiab] OR "Delay* surgery”[tiab]) AND (spinal cord injuries [mh] OR spinal cord injury [tiab] OR
spinal cord injuries [tiab] OR spinal cord contusion [tiab] OR spinal cord transection [tiab] OR injured spinal cord
[tiab] OR traumatic central cord syndrome [tiab])
EMBASE (OvidSP) Exp "Decompression, Surgical"/ OR ("Surgical Decompression" OR "Early versus late surgical decompression"
OR "early surgical decompression" OR "late surgical decompression" OR "delay decompression" OR "immediate
decompression" OR "Delay treatment" OR "Early treatment" OR "Late surgery" OR "Delay surgery").ti,ab. AND
exp spinal cord injuries/ OR ("spinal cord injury" OR "spinal cord injuries" OR "spinal cord contusion" OR "spinal
cord transection" OR "injured spinal cord" OR "traumatic central cord syndrome").ti,ab.

ative Effectiveness Reviews (10). The reviewers rated the ar- 3. Results:
ticles and classified them into three levels of good, fair, and
poor based on their design, biases, sample selection, ran-
3.1. Search and screening results
domization, performance, and outcome report and eventu- In the extended search, 103 potentially eligible studies were
ally, only studies rated as fair and good were included. screened, 29 of which met the inclusion criteria. Among
them, eleven studies had not presented data required for
2.4. Statistical analyses meta-analysis (12-22). Corresponding authors of these stud-
Data on neurologic outcome were reported in two forms ies were contacted and three of them responded (14, 17, 21),
in the studies. Some surveys had compared the mean and two of which provided data (17, 21). No answers were re-
standard deviations of ASIA score or Frankel score between ceived from the authors of the other 8 surveys after sending
the two groups of early and late surgical decompression, two reminders. Therefore, 18 studies were included from the
while others had compered the improvement rate of one/two systematic search. Manual search yielded 4 more articles.
grade(s) in AIS/Frankel score between the two mentioned Eventually 22 studies were included in the meta-analysis
groups. For the studies with the first form, standardized (Figure 1) (4, 17, 21, 23-41).
mean differences (SMD) were calculated with a confidence
interval of 95% (95% CI) based on Hedge’s g. For stud-
3.2. Characteristics of included studies
ies that had compared one/two grade(s) improvement in Included studies comprised of two randomized clinical
AIS/Frankel scores, data were recorded as frequency of im- trials (9.09%), two quasi-experimental studies (9.09%),
proved or not improved patients in each group and a pooled six prospective cohorts (27.27%) and 12 retrospective co-
relative risk (RR) with a confidence interval of 95% was horts (44.55%). These studies had evaluated 6803 patients
reported. Pooled prevalence of post-surgical complications (3665 subjects in the early spinal decompression surgery
was assessed for each group and pooled RR was calculated group and 3138 patients in the late spinal decompression
for comparison of early and late surgery in decreasing post- surgery group). Early surgical decompression was defined
surgical complications. In order to identify publication bias, as performing the operation within 8 hours in three studies
the Egger’s and Begg’s tests were used (11). Heterogeneity (13.64%), 12 hours in one survey (4.55%), 24 hours in 13
was assessed through I2 tests and a p-value of less than 0.1 studies (59.09%), 48 hours in one (4.55%), and 72 hours in
along with an I2 greater than 50 percent were considered four (18.18%). Two studies had assessed patients with com-
as positive heterogeneity. Fixed effect model was used for plete SCIs, one had evaluated patients with incomplete SCIs
homogenous, and random effect model was applied for het- (4.55%) and the rest included both types of injury (86.36%).
erogeneous analyses. Subgroup analysis was performed to Neurologic outcome was assessed in 9 studies (40.91%),
recognize the source of heterogeneity. It is worth mentioning post-surgical complications were evaluated in 3 (13.64%),
that meta-analysis was only carried out when the data were and both of them were compared in 10 surveys (45.45%).
reported by at least three studies. Statistical analyses were Patients were followed for at least 6 months in 9 studies
done via STATA version 12.0 software (STATA Corporation, (40.91%), 12 months in 7 surveys (31.82%) and more than
College Station, TX). A p value less than 0.05 was regarded as 16 months in two studies (9.09%). 19 articles were written
statistically significant in all the analyses. in English , 2 in Farsi (17, 21) and one in Czech (34). Table 1
presents the characteristics of included studies.

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M. Yousefifard et al. 4

RR of early spinal decompression surgery for post-surgical

complications to be 0.84 (95% CI: 0.72-0.99), which indi-
4. Meta-analysis cates that the prevalence of these complications is lower in
patients who had undergone early surgical decompression
4.1. Neurologic outcome (p = 0.035). Subgroup analysis showed that the prevalence
Six studies had compared the neurologic score of patients be- of complications reported in prospective studies was signif-
tween the two groups of early and late spinal decompression icantly lower in the early treatment group compared to the
surgery via mean and standard deviation (26, 30, 35, 37-39), 5 late intervention group (prevalence = 0.36 vs. 0.52; RR=0.77;
of which used the ASIA score (26, 30, 35, 37, 38) and one used p < 0.001). However, the figures reported in retrospective
the Frankel score (39). In this section, no publication bias studies did not differ significantly between the two groups
was observed (p=0.99), but a moderate heterogeneity was ob- (0.28 vs. 0.34; RR=0.95; p = 0.16). Moreover, the prevalence
served (I-squared = 50.5%; p = 0.072). The pooled SMD of of post-surgical complications was found to be significantly
early and late spinal decompression surgery in neurological lower when the procedure was performed within 24 hours
recovery was 0.18 (95% CI: 0.03-0.33). In other words, early compared to later interventions (prevalence = 0.37 vs. 0.51;
surgical decompression led to moderately better neurologic RR=0.77; p < 0.001). This figure was not significantly different
outcome in patients compared to late treatment. Neurologi- whether the patient was treated within 72 hours of injury or
cal improvement rate was used for comparison between the after that (prevalence = 0.28 vs. 0.33; RR=0.99; p = 0.93).
two groups in 14 studies (4, 17, 21, 24, 25, 27, 29, 31, 32, 34,
38-41). The pooled RR was 0.77 (95% CI: 0.68-0.89) for at least
one grade neurological improvement and 0.84 (95% CI: 0.77- 5. Discussion:
0.92) for at least two grade improvement (Figure 2). No publi-
In recent years, spinal decompression surgery in the early
cation bias was found (p=0.66) but a moderate heterogeneity
hours of SCI has drawn major attention. Some believe that
was identified (I-Squared=48.8%; p = 0.02). Subgroup anal-
early surgical decompression in these patients can lead to
ysis was performed to find the source of heterogeneity for
better neurologic recovery and decrease post-surgical com-
at least one grade improvement in neurological status (Ta-
plications. However, disagreements still exist on this matter.
ble 2). Pooled RR yielded from clinical trials was significantly
The present meta-analysis aimed to draw a comprehensive
lower than that of the cohort studies (0.54 vs. 0.81). In other
conclusion on this subject through conducting an extended
words, in clinical trials the efficacy reported for early spinal
search in electronic databases. The findings of this study
decompression surgery was higher than the reports of cohort
showed that early spinal decompression surgery, within 24
studies. Pooled RR for early spinal decompression surgery in
hours of injury, is associated with improved neurologic re-
improvement of neurological outcome was found to be 0.26
covery and decreased post-surgical complications compared
(95% CI: 0.13-0.52; p < 0.001) when the procedure was per-
to late intervention. Definitions of early surgical decom-
formed within 12 hours after injury, 0.75 (95% CI: 0.63-0.90;
pression in different studies vary regarding the temporal
p = 0.002) when performed within 24 hours, and 0.93 (95% CI:
cut-off point, which ranges from 8 to 72 hours. Accordingly,
0.76-1.14; p = 0.48) when carried out within 72 hours. There-
subgroup analysis was performed to assess the neurologic
fore, neurologic improvement declined with the rise in the
recovery of the patients, which indicated that longer interval
interval between injury and surgery, so that there is no signif-
between injury and spinal decompression surgery, is asso-
icant difference between the efficacy of the treatment when
ciated with lower treatment efficacy. Performing surgery
performed within 72 hours or after that. Follow-up period
in the first 12 hours after trauma was associated with the
was another effective factor. Pooled RR for studies with 6
best neurologic recovery, while the outcomes of treatment
month follow-ups was 0.87 (95% CI: 0.75-1.02; p = 0.08), while
within 72 hours and after that did not differ significantly.
it was 0.53 (95% CI: 0.39-0.71; p < 0.001) for studies with at
In this regard, it can be concluded that the optimum time
least 12 month follow-ups.
for surgical decompression is the first 12 hours after injury.
4.2. Post-surgical complications Considering the fact that it is not possible for most patients
to undergo surgery in the first 12 hours, the cut-off point
Post-surgical complications were evaluated in 12 studies (4,
could be considered the first 24 hours. The higher efficacy
17, 23, 25, 26, 29, 31, 33, 35, 36, 38, 40). The prevalence of
of spinal decompression surgery in the first 12 hours can be
complications in the early spinal decompression surgery
attributed to the pathologic mechanism of spinal traumatic
group was 0.29 (95% CI: 0.28-0.31) and in the late group was
injuries. Neural injury occurs during the first hours after SCI
0.38 (95% CI: 0.36-0.40). No publication bias was present
leading to hypo-perfusion, ischemia, and eventually death
(p=0.66) but a significant heterogeneity was observed (I-
of neural cells (first phase of injury), while the majority of
Squared = 65.2%; p = 0.001). Meta-analysis found the pooled

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5 Emergency. 2017; 5 (1): e37

Figure 1: Flowchart of the study.

injuries occur in the second phase, which starts within few the evident publication bias in the study of van Middendrop.
days after trauma. This phase includes apoptosis induction, In their meta-analysis, only two studies with a cut-off point
formation of glial scar, central chromatolysis, disruption in of 24 hours were included for classification of subjects to
expression of myelin genes, myelin destruction in remained two groups of early and late, while the present meta-analysis
axons, glutamate hyper-stimulation, immune cells attacking included 13 of such surveys. In another systematic review
the site of lesion and release of inflammatory cytokines, in 2015, Anderson et al. evaluated 9 studies aiming to assess
endothelial injury induced by reperfusion-ischemia, and the optimal timing of surgical decompression for acute trau-
etc. (42). Hence, decompression in the first hours after matic central cord syndrome and they stated that surgery in
injury can prevent secondary injuries or lower its severity. the first 24 hours is a safe and efficient method. These au-
In line with the results of this study, van Middendrop et thors declared that there is still not enough evidence on this
al. found that surgical intervention in the first 24 hours matter, based on which a solid guideline could be proposed
after injury is associated with better neurologic recovery, for early surgery (43). The present meta-analysis showed
compared to the same treatment after 24 hours (7). However, that the follow-up duration can influence the yielded results.
the efficacy they reported was considerably higher than this No significant difference was found between the neurologic
study. These researchers found that surgery in the first 24 recovery of early and late surgical decompression in studies
hours increases neurologic recovery by 2.5 times, while in with 6 month follow-ups (RR=0.87; 95% CI: 0.75-1.02), while
the present meta-analysis this efficacy was found to be 1.3 evaluating the studies with at least 12 months of follow
times (RR=0.77). This difference could partly be attributed to up showed significant difference between the two groups

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M. Yousefifard et al. 6

Figure 2: Forest plot of neuralgic improvement relative risk (RR) in individual studies and pooled estimate using the random effects model for
comparing early and late surgical decompression.

(RR=0.53; 95% CI: 0.39-0.71). This might be due to the in early and late surgical groups to be considerable but
incomplete neurologic recovery within 6 months. Although statistically insignificant (OR=0.71; 95% CI: 0.49-1.04).(7)
the majority of recoveries occur in the first 3 to 6 months The overall analysis in the present study also found the men-
after injury, to assess the efficacy of a treatment the max- tioned difference to be near the borderline (RR=0.84; 95% CI:
imum improvement should be considered for comparison 0.72-0.99), but when subgroup analysis was performed for
in order to reach more reliable conclusions. Accordingly, it temporal cut-off point, it was illustrated that classification
is suggested that the patients be followed for at least one of patients based on a cut-off point of 72 hours can change
year in the future studies. As presented in this meta-analysis, the differences between the two groups. The differences
lower prevalence of post-surgical complications is another were found to be significant when cut-off point was set
advantage of performing the surgery in the first 24 hours. to 24 hours. Subgroup analysis could not be performed
In their overall analysis, van Middendrop et al. found the based on severity of injury since most included studies had
difference between the rates of post-surgical complications evaluated both complete and incomplete injuries and had

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7 Emergency. 2017; 5 (1): e37

Figure 3: Forest plot of post-surgery complication relative risk (RR) in individual studies and pooled estimate using the random effects model
for comparing early and late surgical decompression.

not separated the two. Another limitation of this study was between timing of surgery and neurologic improvement,
existence of heterogeneity between the included surveys, subgroup analysis was performed based on different factors,
which led to the meta-analysis being designed based on which considerably helped reduce biases.
random effect model for these cases. Although we did our
best to include studies with similar methodologies and
controlling for confounding factors, even in ideal situations 6. Conclusion:
this cannot be completely obtained. For instance, in most
The findings of this meta-analysis showed that early spinal
patients SCIs are accompanied by other injuries, a factor
decompression surgery is associated with better neurologic
that can affect the final outcome of the treatments and
improvement and lower prevalence of post-surgical compli-
prevalence of post-surgical complications but is overlooked
cations, compared to late intervention. The efficacy is most
by most studies. In the present survey, only two clinical
prominent when the surgery is performed within the first
trials and two quasi-experimental studies were included
12 hours after injury. Accordingly, it is recommended that
and the majority of the articles were retrospective studies.
surgical decompression be carried out in the first 12 hours
Therefore, the results could be subject to selection bias. On
after injury and postponing the procedure to later than 24
the other hand, the retrospective nature of these studies
hours is associated with significant decrease in neurologic
could have influenced the collected data, which is indicative
improvement and more post-surgical complications.
of possible bias in this section. Nevertheless, an extended
search was conducted in electronic databases and a great
effort was made to acquire data through contacting the
authors, extracting information from charts and figures, and 7. Appendix
calculation of means and standard deviations. Although the 7.1. Acknowledgements
last two methods are not very precise, the figures they extract
This research has been supported by a Tehran University of
are quite similar to the actual numbers, so these methods
Medical Sciences and Health Services grant and Sina Trauma
are frequently applied in meta-analyses (44, 45). Most
and Surgery Research Center, Tehran University of Medical
importantly, in addition to overall evaluation of the relation

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M. Yousefifard et al. 8

Sciences grant (Number: 94-02-184-26097). 10. Agency for Healthcare Research and Quality. Methods
guide for effectiveness and comparative effectiveness re-
7.2. Authors contribution views: Agency for Healthcare Research and Quality; 2012.
All authors passed four criteria for authorship contribution Available at:. Accessed , 2012; 2012 [cited 2012 September
based on recommendations of the International Committee 12]. Available from: www.effectivehealthcare.ahrq.gov.
of Medical Journal Editors 11. Egger M, Smith GD, Schneider M, Minder C. Bias in
meta-analysis detected by a simple, graphical test. BMJ.
7.3. Conflict of interest 1997;315(7109):629-34.
There are no conflicts of interests to report. 12. Aarabi B, Alexander M, Mirvis SE, Shanmuganathan
K, Chesler D, Maulucci C, et al. Predictors of out-
7.4. Funding come in acute traumatic central cord syndrome due
None declared. to spinal stenosis. J Neurosurg Spine. 2011;14(1):122-30.
doi: 10.3171/2010.9.SPINE09922. Epub 2010 Dec 17.
13. Anderson DG, Sayadipour A, Limthongkul W, Martin ND,
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11 Emergency. 2017; 5 (1): e37

Table 1: Comparison of studied risk factors of preterm delivery between term and pre term pregnancy

Author, Study design Timing Severity Sample Age* Sex Location Outcome Score Follow up (month)
year (hours) size male of in-
(early/late) (%) jury
Bourassa- RCS 24 I/C 90 / 110 47.9±17.677.7 C1-L2 complication NA Post-surgery
Moreau
et al.
2013 5
Bourassa- RCS 24 C 38 / 15 43.7±18.591 C1-L2 Neurologic ASIA 6
Moreau
et al.
2015 6
Cengiz RCT 8 I/C 12 / 15 41.4±14.766.7 T8-L2 Neurologic/complication ASIA 12
et al.
2008 7
Chen Quasi-RCT 8 I/C 99 / 110 42.1 ± 82.8 Cervical Neurologic/complication ASIA/AIS 12
et al. 13.8
2012 8
Dobran RCS 12 I/C 27 / 30 50.2 ± 77.2 Cervical Neurologic AIS 24
et al. 21.3
2015 12
Dvorak PCS 24 I/C 355 / 45.7 76.5 C1-L2 Neurologic/complication ASIA 6
et al. 533
2015 13
Ehsaei Quasi-RCT 24 I 15 / 15 35.9±17.290 T11-L2 Neurologic/complication Frankel 6
et al.
2013 15
Fehlings PCS 24 I/C 131 / 91 47.46±16.9
75.4 Cervical Neurologic/complication AIS 6
et al.
2012 18
Guest RCS 24 I/C 16 / 34 45 (14- 62 Cervical Neurologic ASIA >13
et al. 77)
2002 21
Gupta PCS 48 I/C 23 / 46 35.7±11.588 Cervical Neurologic/complication ASIA 12
et al.
2015 22
Jug PCS 8 I/C 22 / 20 48(25.8- 81 Cervical Neurologic ASIA 6
et al. 72.8)
2015 25
Kerwin RCS 72 I/C 174 / 39.6 72.6 C1-L2 complication NA Post-surgery
et al. 125
2005 27
Liu RCS 72 I/C 172 / 41.4±12.076.6 C3-C7 Neurologic/complication Frankel 6
et al. 317
2015 30
Lukas RCS 24 I/C 15 / 12 NR NR C3-L1 Neurologic Frankel 6
et al.
2012 31
McKinley PCS 24 I/C 33 / 140 37.65±15.83
78.8 C3-L2 Neurologic/complication ASIA 12
et al.
2004 32
Medress RCS 72 I/C 2249 50.34 68.9 Cervical complication NA Post-surgery
et al. /1099
2015 33
Pollard RCS 24 C 86 / 242 35±15.5 NR Thoracic Neurologic ASIA 12
et al.
2003 37
*, data were present as mean ± standard deviation or mean and (range). RCS: Retrospective cohort study;
PCS: Prospective cohort study; RCT: Randomized control trial; I: Incomplete injury; C: Complete injury; NEU: Neurologic;
COMP: complication; ASIA: American Spinal; Injury Association; AIS: American Spinal Injury Association Impairment Scale Impairment
Scale; NR: Not reported; NA: Not applicable.

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M. Yousefifard et al. 12

Table 1: Comparison of studied risk factors of preterm delivery between term and pre term pregnancy (Continue)

Author, Study design Timing Severity Sample Age* Sex Location Outcome Score Follow up (month)
year (hours) size male of in-
(early/late) (%) jury
Rahimi RCS 24 I/C 12 / 32 26.7 ± 90 C3-L2 Neurologic Frankel 6
et al. 8.6
2005 39
Rahimi RCT 24 I/C 15 / 18 35±12.1 71 T5-L1 Neurologic/complication AIS 12
et al.
2014 38
Sapkas RCS 72 I/C 31 / 36 36 (16- 73.1 C3-C7 Neurologic Frankel 12
et al. 72)
2007 41
Stevens RCS 24 I/C 16 / 34 47.7±16.282 Cervical Neurologic/complication Frankel 16
et al. tho-
2010 44 racic
Umerani PCS 24 I/C 34 / 64 39.2 78.6 C3-T1 Neurologic AIS 6
et al. (19-65)
2014 45
*, data were present as mean ± standard deviation or mean and (range). RCS: Retrospective cohort study;
PCS: Prospective cohort study; RCT: Randomized control trial; I: Incomplete injury; C: Complete injury; NEU: Neurologic;
COMP: complication; ASIA: American Spinal; Injury Association; AIS: American Spinal Injury Association Impairment Scale
Impairment Scale; NR: Not reported; NA: Not applicable.

Table 2: Subgroup analysis of at least one improvement in neurological status for comparing early and late surgical decompression

Characteristic No of subject (early/late) P for publication bias * Model p for Heterogeneity Relative risk (95% P
(I2 ) CI)
Overall 553 /745 0.66 FEM 0.02 (48.8%) 0.77 (0.68-0.88) 0.02
Data gathering
method
Prospective 242 /269 0.55 FEM 0.22 (26.8%) 0.70 (0.68-0.89) <0.001
Retrospective 311 /476 >0.99 REM 0.02 (59.9%) 0.85 (0.71-1.03) 0.09
Type of study
Cohort 511 /697 0.92 FEM 0.03 (49.1%) 0.81 (0.70-0.93) 0.003
Control trial 42 /48 0.73 FEM 0.19 (40.1%) 0.54 (0.39-0.81) 0.003
Time cut off#
8-12 hours 39 /45 >0.99 FEM 0.55 (0.0%) 0.26 (0.13-0.52) <0.001
0-24 hours 216 /399 0.76 FEM 0.90 (0.0%) 0.75 (0.63-0.90) 0.002
0-72 hours 298 /301 0.73 REM 0.05 (66.6%) 0.93 (0.76-1.14) 0.48
Location of injury
Cervical 403 /604 0.73 REM 0.02 (62.1%) 0.82 (0.71-0.94) 0.008
Thoracolumbar 42 /48 0.31 FEM 0.19 (40.1%) 0.54 (0.36-0.81) 0.003
Follow up period
6 months 403 /604 0.73 REM 0.11 (40.4%) 0.87 (0.75-1.02) 0.08
≥ 12 months 42 /48 0.31 FEM 0.12 (42.2%) 0.53 (0.39-0.71) <0.001
* Based of Egger’s (Begg’s) test
#, Time cut point for definition of early surgery group
REM: Random effect model; FEM: Fixed effect; CI: Confidence interval.

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13 Emergency. 2017; 5 (1): e37

Table 3: Subgroup analysis of at least one improvement in neurological status for comparing early and late surgical decompression

Prevalence Publication bias* (P value) Model p for Hetero- Relative risk P

Characteristic
(95% CI) geneity (I2 ) (95% CI)
Early group Late group

Overall 0.29 (0.28-0.31) 0.38 (0.36-0.40) 0.66 FEM 0.001 (65.2%) 0.84 (0.72-0.99) 0.035
Data gathering
method
Prospective 0.36 (0.32-0.39) 0.52 (0.48-0.56) FEM 0.22 (26.8%) 0.77 (0.68-0.87) <0.001

Retrospective 0.28 (0.27-0.30) 0.34 (0.32-0.36) 0.81 REM 0.003 (75.0%) 0.95 (0.76-1.19) 0.16
Type of study
Cohort 0.37 (0.30-0.45) 0.55 (0.48-0.63) 0.71 REM 0.001 (71.3%) 0.87 (0.73-1.03) 0.10
Control trial 0.29 (0.28-0.31) 0.37 (0.35-0.39) >0.99 REM 0.05 (60.8%) 0.50 (0.21-1.19) 0.12
Time cut off#
0-24 hours 0.37 (0.34-0.41) 0.51 (0.47-0.55) 0.37 FEM 0.17 (32.4%) 0.77 (0.68-0.86) <0.001
0-72 hours 0.28 (0.26-0.29) 0.33 (0.31-0.36) >0.99 REM 0.003 (78.6%) 0.99 (0.77-1.27) 0.93
Location of in-
jury
Cervical 0.29 (0.27-0.30) 0.36 (0.34-0.38) >0.99 REM 0.001 (79.5%) 0.89 (0.72-1.11) 0.30
Thoracolumbar 0.11 (0.0-0.22) 0.41 (0.28-0.54) >0.99 FEM 0.64 (0.0%) 0.33 (0.15-0.73) 0.006
* Based of Egger’s (Begg’s) test.
#, Time cut point for definition of early surgery group.
REM: Random effect model; FEM: Fixed effect; CI: Confidence interval.

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