The race against time: patterns and variables of spine surgery timing in traumatic spinal cord injury: a retrospective cohort study from the TraumaRegister DGU®.

Background: Numerous uncontrolled observational studies suggest that early spinal decompression and stabilization within 24 h of spinal cord injury (SCI) improve neurological recovery, forming the basis for recently published best practice guidelines. In this study, we aim to investigate current surgical practices in trauma centers across Germany, Austria, and Switzerland and to elucidate trauma- and patient-related factors influencing the timing of spine surgery.

Methods: We identified patients aged 16 years or older with traumatic SCI and permanent neurological deficits from the TraumaRegister DGU^® of the German Trauma Society (2008-2022). Trauma severity was assessed using the Abbreviated Injury Scale. Patients were categorized based on the timing of spine surgery (early surgery: day of admission; late surgery: subsequent days) and functional impairment (moderate vs. severe, based on the Glasgow Outcome Scale). Multivariate regression analyses were conducted to correlate patient and trauma-related factors with these endpoints.

Results: A total of 9938 patients with SCI at cervical, thoracic, and lumbar levels were identified. Among the 5025 patients who underwent spine surgery, 69% were operated on the day of admission, while 31% received surgery on subsequent days. Elderly patients (≥ 60 years) had a higher likelihood of delayed surgery (odds ratio [OR] 0.68-0.76). Trauma-related factors, including high cervical SCI, significant injuries beyond the spine, traumatic brain injury, and signs of hemorrhage, were strongly associated with late surgery (OR 0.38-0.83; p < 0.05). Conversely, patients with complete SCI or SCI at the thoracic or lumbar levels were more likely to undergo early surgery (OR 1.45-1.8; p < 0.001). Severe functional impairment was associated with advanced age (≥ 70 years), complete SCI, high cervical SCI, concomitant traumatic brain, signs of hemorrhage and comorbidities (OR 1.27-4.59; p < 0.01), whereas SCI at thoracic (OR 0.8) and lumbar (OR 0.4) levels correlated with moderate functional impairment (p < 0.01).

Conclusion: The majority of SCI patients in trauma centers across Germany, Austria, and Switzerland undergo early spinal surgery, reflecting adherence to best practice recommendations. Timing of surgery is significantly influenced by patient age and trauma complexity. Delays are more common in elderly patients and those with high cervical injuries or associated trauma, underscoring the need for individualized surgical decision-making. Given the strong correlation between injury severity, surgical timing, and functional impairment, future guidelines should refine criteria for early intervention to further optimize neurological recovery.