AO Spine and the PRAXIS Institute release new clinical practice guidelines for acute spinal cord injury (SCI)
BY BRIAN KWON, MICHAEL FEHLINGS, LINDSAY TETREAULT, AND NATHAN EVANIEW
Researchers from AO Spine and Praxis Spinal Cord Institute in Vancouver, Canada, have published a new set of clinical practice guidelines for the treatment of acute spinal cord injury (SCI). These guidelines play a major role in making treatment decisions for example in the timing of surgical decompression and the hemodynamic management in cases of acute SCI. Despite the mounting evidence, implementing guidelines into daily clinical practice is challenging—given biases towards clinicians’ hardened routines or material deficiencies in different global health contexts.
When managing complex conditions such as acute spinal cord injury, surgeons and other health care practitioners want to be certain that what they are doing in the operating theater is in line with the latest scientific data. They require practical resources that help them make the best possible decision in any given situation. However, they frequently do not have the time to keep abreast of all the relevant research.
This is where clinical practice guidelines come in: they are a synthesis of the best and newest data, systematically reviewed and edited into a collection of actionable recommendations. In our case, we focused on three specific aspects of acute SCI: the timing of surgical decompression, hemodynamic management, and perioperative SCI.
Role and timing of surgery
It is widely accepted today that SCI patients who receive early surgical decompression have better neurological outcomes. In 2017, AO Spine and the Cervical Spine Research Society issued a guideline recommending surgical intervention within 24 hours as the preferred treatment option for the first time. However, the level of evidence supporting the recommendation at the time was weak.
For our new guidelines, we were able to use more recent evidence to quantitatively show that early intervention enhances recovery based on the scores of the ASIA Impairment Scale—something we were not able to show in the 2017 guideline.
Hemodynamic management
We also updated a 2013 guideline on hemodynamic management in cases of acute SCI. Ensuring that there is enough blood perfusion and oxygenation to the spinal cord—hemodynamic management—represents one of the few opportunities for clinicians to potentially improve neurological outcomes after an injury.
Previously, the recommendation was to maintain mean arterial pressure (MAP) between 85 to 90 millimeters of mercury (mmHg) for a duration of seven days after an injury. However, neither the target MAP nor the seven-day treatment period were well-substantiated by clinical evidence. Our update to the guideline therefore acknowledges that while hypotension should be avoided, the exact target MAP and treatment duration remain somewhat uncertain. This knowledge gap is a big deal for many hospitals, because it determines how long a patient will need to remain in the intensive care unit. It also underpins the need for more high-quality studies on the subject.
Intra-operative SCI
Intra-operative SCI (ISCI), a spinal cord injury that occurs during an operation, is an intrinsic risk to any spinal surgery, but there had not previously been a guideline on the issue. However, a survey of the international membership of AO Spine showed a significant interest and need amongst clinicians to be better informed on the topic.
Our new guideline is the first attempt to deliver a comprehensive definition of ISCI. We also identified a series of ISCI risk factors through a scoping review and investigated the diagnostic accuracy of intraoperative neuromonitoring (IONM) techniques, which are used to monitor neurological function during complex procedures. Our conclusion is that there is sufficient high-quality evidence to recommend considering the use of IONM for high-risk patients undergoing spine surgery. We also propose a comprehensive five-step approach to the management of ISCI.
Spreading the word
Although the actual guidelines are complete for now, their publication in the Global Spine Journal is only the beginning. Guidelines do not implement themselves, and we must now turn our attention towards the knowledge translation effort to ensure that the guidelines are disseminated far and wide so that clinicians around the world can learn about them and integrate them into their daily practice.
We did not tackle our topics by accident—these are the things that we know spine surgeons and acute care practitioners struggle with. We are confident that these guidelines will enhance practice, address key knowledge gaps, and ultimately enhance outcomes for patients with SCI.
Additional links:
The Guidelines study was conducted by the AO Spine Knowledge Forum Spinal Cord Injury and the Praxis Spinal Cord Institute.
The full guest article was published in the AO Spine Guest Blog under the title New clinical practice guidelines for acute spinal cord injury (aofoundation.org).
About the Authors
