Hadley, Mark N. MD*; Walters, Beverly C. MD, MSc, FRCSC‡
*Co-Lead Author, Guidelines Author Group; Charles A. & Patsy W. Collat Professor of Neurosurgery and Program Director, University of Alabama Neurosurgical Residency Training Program, Division of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama
‡Co-Lead Author, Guidelines Author Group; Professor of Neurological Surgery and Director of Clinical Research, University of Alabama at Birmingham, Birmingham, Alabama; Professor of Neurosciences, Virginia Commonwealth University - Inova Campus and Director of Clinical Research, Department of Neurosciences, Inova Health System, Falls Church, Virginia; Affiliate Professor of Molecular Neurosciences, George Mason University, Fairfax, Virginia
Medical evidence-based guidelines, when properly produced, represent a contemporary scientific summary of accepted management, imaging, assessment, classification, and treatment strategies on a focused series of medical and surgical issues.1-3 They are an evidence-based hierarchal ranking of the scientific literature produced to date. They record and rank the collective experiences of scientists and clinicians and are a comprehensive reference source on a given topic or group of topics.
Medical evidence-based guidelines are not meant to be restrictive or to limit a clinician's practice. They chronicle multiple successful treatment options (for example) and stratify the more successful and the less successful strategies based on scientific merit. They are not absolute, “must be followed” rules. This process may identify the most valid and reliable imaging strategy for a given injury, for example, but because of regional or institutional resources, or patient co-morbidity, that particular imaging strategy may not be possible for a patient with that injury. Alternative acceptable imaging options may be more practical or applicable in this hypothetical circumstance.
Guidelines documents are not tools to be used by external agencies to measure or control the care provided by clinicians. They are not medical-legal instruments or a “set of certainties” that must be followed in the assessment or treatment of the individual pathology in the individual patients we treat. While a powerful and comprehensive resource tool, guidelines and the recommendations contained therein do not necessarily represent “the answer” for the medical and surgical dilemmas we face with our many patients.
This second iteration of Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries represents 15 months of diligent volunteer effort by the Joint Section on Disorders of the Spine and Peripheral Nerves author group to provide an up-to-date review of the medical literature on 22 topics germane to the care, assessment, imaging and treatment of patients with acute cervical spine and/or spinal cord injuries. The medical evidence summarized within each guideline has been painstakingly analyzed and ranked according to rigorous evidence-based medicine criteria, and have been linked to 112 evidence-based recommendations for these topics.1-3
There are many important differences in this iteration of these Guidelines compared to those we published 10 years ago. Regrettably, however, for some of the topics considered and included in this medical evidence-based compendium, little new evidence beyond Class III medical evidence has been offered in the last 10 years by investigators and surgeons who treat patients with these disorders. Our specialties and our patients desperately need comparative Class I and Class II medical evidence derived from properly designed analytical clinical studies to further our understanding on the best ways to assess, diagnose, image and treat patients with these acute traumatic injuries.
Good progress has been made in several clinical research areas since the original Guidelines publication in 2002. One hundred twelve evidence-based recommendations are offered in this contemporary review, compared to only 76 recommendations in 2002. There are 19 Level I recommendations in the current Guidelines; each supported by Class I medical evidence.
* Assessment of Functional Outcomes (1)
* Assessment of Pain After Spinal Cord Injuries (1)
* Radiographic Assessment (7)
* Pharmacology (2)
* Diagnosis of AOD (1)
* Cervical Subaxial Injury Classification Schemes (2)
* Pediatric Spinal Injuries (1)
* Vertebral Artery Injuries (1)
* Venous Thromboembolism (3)
There are an additional 16 Level II recommendations based on Class II medical evidence and 77 Level III recommendations based on Class III medical evidence.
The Table shows the differences in the recommendations between the 2 sets of guidelines. One key change is that in nomenclature: “Standards” has been replaced by “Level I,” “Guidelines” has been replaced by “Level II,” and “Options” has been replaced by “Level III,” as described in detail in the Methodology section of these guidelines. Not every recommendation is listed since some have not changed, and the statement “No changes in recommendations” indicates that. When they have changed, the recommendations previously made are compared to those being made currently. Where we have introduced new recommendations not included in the previous iteration of the guidelines, a statement is found indicating what the recommendations are alongside “None” and “Not addressed,” which represents the lack of previous recommendations on a particular aspect or topic. This summary table highlighting the changes in the guidelines is not a substitute for reading and understanding this new version of the recommendations that reviews and evaluates extant literature in detail.
TABLE-a Comparison o...Image Tools
This comprehensive guidelines update does not contain an evidence-based summary or recommendation on several topics important to the care of our patients, our profession, and our disciplines, simply because there is not enough definitive medical evidence in the literature on those topics to allow such a review. Emerging science in the repair and regeneration of spinal cord injuries,4 emerging technology in imaging, the use of electrophysiological monitoring during surgery for spinal cord injury, new engineering technology in surgical implants,5 hypothermia in the care of the spinal cord injured patient6 and new science on the issue of the timing of surgery after acute traumatic cervical spinal injury,7,8 are examples of topics we simply do not have enough meaningful or convincing medical evidence in our literature to be included in this scientific review of acute cervical spine and spinal cord injuries.
The author group and the Joint Section leadership hope that these guidelines will serve their intended valuable purpose. The issues addressed in this scientific compendium are germane to the assessment, management, treatment, and study of the growing population of acute traumatic cervical spine and spinal cord injury patients we see daily in our practices. These patients, their injuries, their care, and in many cases, their losses, personally and to society, are a major and growing societal and healthcare burden in the United States and around the world.9
1. Hadley MN, Walters BC, Grabb PA, et al.. Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery. 2002;50(3 suppl):S1–S199.
2. Field M, Lohr K, eds. Clinical Practice Guidelines: Directions for a New Program—Committee to Advise the Public Health Service on Clinical Practice Guidelines: Institute of Medicine. Washington, DC: National Academy Press; 1990.
3. Walters B. Clinical practice parameter development in neurosurgery. In: Bean J, ed. Neurosurgery in Transition: The Socioeconomic Transformation of Neurological Surgery. Baltimore, MD: Williams & Wilkins; 1998:99–111.
4. Kwon BK, Sekhon LH, Fehlings MG. Emerging repair, regeneration, and translational research advances for spinal cord injury. Spine (Phila Pa 1976). 2010;35(21 suppl):S263–S270.
5. Walters BC. Oscillating field stimulation in the treatment of spinal cord injury. PM R. 2010;2(12 suppl 2):S286–S291.
6. Dietrich WD, Levi AD, Wang M, Green BA. Hypothermic treatment for acute spinal cord injury. Neurotherapeutics. 2011;8(2):229–239.
7. Fehlings M, Vaccaro A, Aarabi B, et al.. A prospective, multicenter trial to evaluate the role and timing of decompression in patients with cervical spinal cord injury: Initial one year results of the STASCIS study. Presented at: American Association of Neurological Surgeons Annual Meeting; 2008; Denver, CO.
8. Fehlings MG, Wilson JR. Timing of surgical intervention in spinal trauma: what does the evidence indicate? Spine (Phila Pa 1976). 2010;35(21 suppl):S159–S160.
9. Baaj AA, Uribe JS, Nichols TA, et al.. Health care burden of cervical spine fractures in the United States: analysis of a nationwide database over a 10-year period. J Neurosurg Spine. 2010;13(1):61–66.