National Trends in Time to Surgery for Traumatic Spinal Cord Injury in the United States: An Analysis of the National Trauma Data Bank

Abstract

The current guidelines recommend that patients with spinal cord injury (SCI) undergo rapid decompressive surgery, ideally within 24 h, to reduce cord ischemia and improve outcomes. National trends in treatment times in the United States, and the factors limiting the timely surgical management of SCI, remain incompletely understood. A retrospective review of the National Trauma Data Bank (NTDB) from 2017 to 2021, which encompasses the years following the publication of the Arbeitsgemeinschaft für Osteosynthesefragen Spine guidelines suggesting early surgery, was performed. The included patients had sustained SCI requiring surgical management, were aged >18 years, were treated at a level I or II trauma center, and had no major trauma-related cranial, abdominal, or thoracic surgery prior to spine surgery. Mixed-effects models were used to identify the key factors at the patient and facility levels associated with time to surgery. The final cohort included 19,513 patients, of which 3,894 (19.9%) underwent surgery within 8 h and 10,634 (54.5%) underwent surgery within 24 h. The average time to surgery for patients admitted in 2018–2019 did not differ from 2017, whereas patients admitted in 2020 (−4.58 h, 95% confidence interval [CI] [−6.09, −3.07], p < 0.001) and 2021 (−2.17 h, 95% CI [−3.65, −0.68], p = 0.004) had significantly shorter times to surgery. Older patients experienced delays of 0.25 h per year of age (95% CI [0.22, 0.27], p < 0.001). Medicare status delayed surgery by 5.81 h (95% CI [4.81, 6.81], p < 0.001). When compared with patients arriving by helicopter ambulance, patients who self-transported (11.57 h, 95% CI [9.26, 13.90], p < 0.001) or were transported by ground ambulance (5.93 h, 95% CI [4.90, 6.96], p < 0.001) experienced significant delays. Pre-frail (5.88 h, 95% CI [5.02, 6.74], p < 0.001) or frail (10.15 h, 95% CI [8.62, 11.68], p < 0.001) patients by the 11-item modified frailty index had increased time to surgery. Patients with cervical injuries had significantly longer times to surgery compared with those with cervicothoracic (−3.42 h, 95% CI [−5.56, −1.28], p = 0.002) or thoracic injuries (−6.29 h, 95% CI [−7.54, −5.05], p < 0.001). Treatment at teaching hospitals (−1.18 h, 95% CI [−2.18, −0.37], p = 0.001) and level I trauma centers (1.41 h, 95% CI [−2.50, −0.53], p = 0.003) reduced the time to surgery in comparison with non-teaching and level II trauma hospitals. In summary, older age, pre-existing frailty, cervical injury, Medicare insurance status, and transportation by ground ambulance or self-transportation are associated with prolonged time to surgery, while treatment at teaching hospitals and level I trauma centers is linked to more rapid intervention. These results suggest that rapid emergency medical systems transport and management at high-resource trauma centers may minimize surgical delays. Despite improvements in later years, nearly half of patients did not meet 24-h operative standards, and only one in five met 8-h targets, underscoring persistent variability in practice patterns and opportunities to better align care with the established guidelines.