Characteristics and Clinical Outcomes of Transition from Conservative Therapy to Surgical Intervention in Older Patients with Cervical Spinal Cord Injury without Major Bone Injury: A Nationwide Retrospective Study

Introduction: Cervical spinal cord injury (CSCI) without major bone injury is increasing among older adults, particularly in aging societies like Japan. The optimal treatment strategies remain unclear, with conservative therapy often preferred, especially for older patients. However, surgery is frequently necessary due to poor improvement or progression of paralysis during conservative treatment. This study investigated the characteristics and outcomes of older patients with CSCI without major bone injury who transitioned from conservative treatment to surgery. Methods: This nationwide, retrospective study examined data from patients aged 65 years with CSCI without major bone injury. The patients were categorized into 3 groups: conservative treatment, planned surgery, and those who switched from conservative treatment to surgery. The study aimed to identify the risk factors for conservative therapy failure that necessitate surgical intervention and to compare the outcomes between patients who had planned surgery and those who required surgery after conservative management failed. Results: Among 615 patients, 422 (68.6%) received conservative treatment, 193 (31.4%) had planned surgery, and 116 (18.9%) transitioned from conservative to surgical treatment. Transition to surgery was mainly due to poor improvement or progression of neurological deficits. Significant risk factors for transitioning to surgery included younger age, presence of ossification of the posterior longitudinal ligament, and spinal cord signal changes on magnetic resonance imaging. Comparative analysis showed no significant differences in neurological outcomes between patients who had surgery as planned and those who required surgery after failed conservative treatment. Conclusions: A significant proportion of older patients with CSCI without major bone injury who were initially managed conservatively eventually required surgery due to insufficient neurological improvement. The outcomes of patients who transitioned to surgery were similar to those who had surgery as initially planned, indicating that careful monitoring of conservative treatment followed by surgery, if necessary, may be an effective approach.