In the first hours after a severe spinal cord injury, Jonathan Yun, MD, is trying to control what can still be controlled: blood pressure, oxygenation, blood loss, the stability of the patient, and the location and extent of the injury. Whether the spinal cord remains compressed.
Then comes the harder part. Even after a surgeon has decompressed the spinal cord and stabilized the spine, the eventual neurological recovery can remain uncertain. That divide, between what surgery can accomplish and what biology must do afterward, shapes how Dr. Yun, a neurosurgeon and spine surgeon with Ridgewood-based Neurosurgeons of New Jersey, thinks about some of spine surgery’s most devastating injuries.
“My job is to really get your nerves and your spinal cord out of harm’s way,” Dr. Yun told Becker’s. “What I can do is get them in an environment where they’re safe.” After that, he said, “the body does take over.”
That has made one of the field’s remaining limitations increasingly clear. Surgeons can control much of what happens in the operating room. They still cannot control how the spinal cord heals.
The first examination is important. It is not the whole prognosis.
A patient arriving with profound neurological deficits after a traumatic spinal cord injury presents clinicians with two simultaneous problems. The first is immediate. Before focusing exclusively on the spine, Dr. Yun said clinicians have to stabilize the patient medically. Blood loss, blood pressure, breathing and oxygenation can all influence what happens next.
Surgeons then have to locate the neurological injury, understand its anatomy through imaging and determine whether decompression and stabilization are necessary. Those first hours matter. But they do not reveal everything. Two patients can arrive with injuries that appear similar on imaging and ultimately follow very different paths.
“Not every patient is the same,” Dr. Yun said. “Everybody is an individual.” MRI findings, such as edema or hemorrhage may indicate injury to the neurological structures themselves beyond the compression caused by a fracture or dislocation. Age and other medical factors can matter. So can the amount of time that passes before treatment.
A patient whose injury is witnessed and who receives rapid medical attention is in a fundamentally different position from someone who remains injured for hours before being found, Dr. Yun said, even if their underlying spinal injuries appear similar. That uncertainty makes the initial neurological examination important without making it definitive. Dr. Yun pays close attention to what happens next. Even incremental improvement during the first days or week can be meaningful.
He asks patients to think less about a single snapshot and more about a “trend line.” If neurological function begins moving in the right direction, even slowly, those early gains can signal the potential for continued recovery over a much longer period.
If surgeons cannot guarantee neurological recovery, they can try to give the spinal cord the best possible conditions in which to recover. That has intensified the focus on timing. General recommendations call for surgical intervention within 24 hours when appropriate, Dr. Yun said, though the condition of the patient ultimately determines whether that is possible.
Spinal cord injuries can accompany significant blood loss, lung injuries and other trauma that make immediate surgery unsafe. The decision becomes a risk-benefit calculation. Once a patient can safely undergo surgery, however, Dr. Yun’s approach centers on three priorities: “Rapid diagnosis, rapid stabilization, rapid intervention.”
The best technology reduces what the patient has to recover from
Dr. Yun points to minimally invasive approaches, computer-guided navigation, robotic assistance and intraoperative imaging as tools that can make certain operations safer and more efficient. In an acute spinal cord injury, those efficiencies carry particular significance. The patient has already sustained substantial trauma. Surgery inevitably adds another physiological burden.
The goal is to accomplish the necessary reconstruction while minimizing that additional burden. Dr. Yun has found minimally invasive techniques particularly useful when the injury and anatomy make them appropriate. Smaller approaches can reduce blood loss, infection risk, surgical time and tissue disruption. “If you can reduce that surgical recovery time and really get them on the path to functional rehabilitation quickly, that’s also very important,” he said.
Intraoperative imaging has changed what surgeons can see during the operation as well. Fractures and dislocations can distort the anatomy surgeons traditionally use as landmarks. Intraoperative CT and navigation can provide real-time anatomical information, helping surgeons accurately target implants and assess whether they have achieved the intended correction and decompression before leaving the operating room.
The value of those technologies, in Dr. Yun’s view, is not simply that they make an operation more sophisticated. It is that they can help surgeons accomplish the same essential goals while giving an already injured patient less to recover from.
Surgery ends. Recovery does not.
There is a point in the spinal cord injury journey when the surgeon’s ability to directly influence neurological recovery diminishes. Decompression can remove an ongoing threat to the spinal cord. Stabilization can protect the injured spine. Neither can dictate how much neurological function returns.
Once surgery has created a safer environment, healing increasingly depends on biology, rehabilitation and time. That distinction can be difficult for patients because a technically successful operation does not mean neurological function will return immediately, or at all. Progress can be slow enough that patients may not recognize it from one day to the next.
That is one reason Dr. Yun does not view the surgeon-patient relationship as ending when the incision heals. “The relationship between a patient and their spine surgeon is an ongoing one,” he said.
At follow-up visits separated by months, he may detect changes that are almost invisible to someone living through recovery every day: an arm slightly stronger, a leg beginning to move differently or sensation changing. Those incremental gains can provide an objective measure of progress during a recovery that otherwise feels stagnant.
Dr. Yun is careful not to promise where that trajectory will end. “It’s impossible to predict the future,” he said. But he is equally reluctant to treat slow progress as proof that recovery has stopped. Neurological recovery can continue over months or even years, making rehabilitation and continued follow-up critical parts of the process.
The next frontier is no longer the operation
The fundamentals of acute spinal cord injury care remain recognizable from Dr. Yun’s training: medical stabilization, rapid diagnosis and, when appropriate, surgical decompression and stabilization.
What has advanced substantially is surgeons’ ability to execute those steps. Minimally invasive approaches can reduce surgical trauma. Navigation and imaging can improve accuracy. Modern operating rooms can give surgeons real-time information about anatomy that has been distorted by injury. Dr. Yun believes the next major advance will have to address something surgery cannot currently repair. “I think the next frontier is really focusing on the biology of the neurologic structures,” he said.
He points to work elsewhere in neuroscience, including efforts to improve functional recovery after stroke, as an indication of where spinal cord injury treatment may eventually move.
The question is whether clinicians can find ways to enhance recovery of the nerves themselves after the mechanical threat has been removed. That would mark a fundamental shift in what spinal cord injury treatment can accomplish.
A prognosis is a snapshot. Recovery is a trajectory.
For now, uncertainty remains part of spinal cord injury care. Severity matters. Timing matters. Imaging matters. Medical stability matters. Rehabilitation matters.
None can tell a surgeon with complete certainty what a particular patient will be able to do months or years later. That is why Dr. Yun is reluctant to let the earliest, and often most devastating, phase of an injury define the entire recovery.
“The journey is a long one,” he said. “Progress may be slow. But the idea is that it is forward progress, regardless.”
Modern spine surgery can increasingly control what happens around an injured spinal cord: relieve compression, restore stability and minimize some of the additional trauma required to do it. What it cannot yet control is how the nervous system responds afterward. For Dr. Yun, that is where the next major breakthrough in spinal cord injury care will have to come.
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