Authors' objectives:

The review aims to examine the following four questions:

- the effectiveness and cost-effectiveness of spinal fixation surgery

- immediate versus delayed referral to a spinal injuries unit (SIU)

- how many people with a new spinal cord injury (SCI) are discharged from hospital without ever being transferred to an SIU

- the effectiveness and cost-effectiveness of steroids for people with SCI.

Authors' recommendations: Only retrospective observational studies were found which assessed spinal fixation surgery or delayed referral to SIUs. In most studies there was doubt over the comparability of groups, at baseline and on confounding factors. Although there was evidence to suggest some benefits of fixation surgery and also a benefit of immediate referral to SIUs compared with delayed or no referral, owing to the limitations of the data these should be interpreted with caution. In general, there was little investigation of the implications of the interventions from the point of view of the patients, relatives or partners. Primary qualitative research should be carried out among users to understand what outcomes are important, and patients should be involved in study design. Data on effectiveness of spinal fixation surgery is high in quantity but low in quality. Spinal fixation does not appear to offer advantages in terms of neurological improvement, length of hospital stay or urinary status. Spinal fixation patients experienced less mortality, spinal instability or psychological problems. They were more likely to be mobile in a shorter time and independent in activities of daily living than non-fixation groups. They were more likely to experience wound infection, device failure and loss of spine flexibility. Not enough data were found to assess whether surgery is most beneficial when carried out in SIUs. Further research of higher quality is required in this area. Patients undergoing immediate referral to SIUs may experience better outcomes than patients whose referral is delayed, or who are treated elsewhere. Owing to the questionable comparability of groups in the majority of studies, the evidence to support this conclusion is weak. Well-designed prospective observational studies with appropriately matched controls are needed. High-dose methylprednisolone steroid therapy may be effective in promoting some degree of neurological recovery if given within 8 hours of injury. There is a need for more RCTs of pharmacological therapy for acute SCI. We found no published studies of any design which would help to answer the question of how many people with acute SCI are discharged from hospital without ever being transferred to an SIU. Primary research involving audit of selected hospital records or a search of national hospital activity data should be commissioned and published. The search strategy did not identify any full economic evaluations, that is, no study considered the costs as well as the impact on patient outcomes of a given intervention. Future research should include full economic evaluations, possibly alongside a large RCT, which fully consider the costs and consequences of implementing interventions.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.hta.ac.uk/1274

Year Published: 2003

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: England, United Kingdom

Organisation Name: NIHR Health Technology Assessment programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk

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