scholarly journals A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus >24 Hours) of Decompressive Surgery

2017 ◽  
Vol 7 (3_suppl) ◽  
pp. 195S-202S ◽  
Author(s):  
Michael G. Fehlings ◽  
Lindsay A. Tetreault ◽  
Jefferson R. Wilson ◽  
Bizhan Aarabi ◽  
Paul Anderson ◽  
...  
Keyword(s):  
Systematic Review ◽  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Clinical Practice ◽  
Guideline Development ◽  
Surgical Decompression ◽  
Early Surgery ◽  
Clinical Expertise ◽  
Cord Injury ◽  
Central Cord Syndrome

Objective: To develop recommendations on the timing of surgical decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome. Methods: A systematic review of the literature was conducted to address key relevant questions. A multidisciplinary guideline development group used this information, along with their clinical expertise, to develop recommendations for the timing of surgical decompression in patients with SCI and central cord syndrome. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weak recommendation is presented as “we suggest.” Results: Conclusions from the systematic review included (1) isolated studies reported statistically significant and clinically important improvements following early decompression at 6 months and following discharge from inpatient rehabilitation; (2) in one study on acute central cord syndrome without instability, a marginally significant improvement in total motor scores was reported at 6 and 12 months in patients managed with early versus late surgery; and (3) there were no significant differences in length of acute care/rehabilitation stay or in rates of complications between treatment groups. Our recommendations were: “We suggest that early surgery be considered as a treatment option in adult patients with traumatic central cord syndrome” and “We suggest that early surgery be offered as an option for adult acute SCI patients regardless of level.” Quality of evidence for both recommendations was considered low. Conclusions: These guidelines should be implemented into clinical practice to improve outcomes in patients with acute SCI and central cord syndrome by promoting standardization of care, decreasing the heterogeneity of management strategies, and encouraging clinicians to make evidence-informed decisions.

scholarly journals A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Rehabilitation

2017 ◽  
Vol 7 (3_suppl) ◽  
pp. 231S-238S ◽  
Author(s):  
Michael G. Fehlings ◽  
Lindsay A. Tetreault ◽  
Bizhan Aarabi ◽  
Paul Anderson ◽  
Paul M. Arnold ◽  
...  
Keyword(s):  
Systematic Review ◽  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Clinical Practice ◽  
Guideline Development ◽  
Management Strategies ◽  
Acute Spinal Cord Injury ◽  
Clinical Expertise ◽  
Assessment Development ◽  
Cord Injury

Introduction: The objective of this study is to develop guidelines that outline the appropriate type and timing of rehabilitation in patients with acute spinal cord injury (SCI). Methods: A systematic review of the literature was conducted to address key questions related to rehabilitation in patients with acute SCI. A multidisciplinary guideline development group used this information, and their clinical expertise, to develop recommendations for the type and timing of rehabilitation. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest. Results: Based on the findings from the systematic review, our recommendations were: (1) We suggest rehabilitation be offered to patients with acute spinal cord injury when they are medically stable and can tolerate required rehabilitation intensity (no included studies; expert opinion); (2) We suggest body weight–supported treadmill training as an option for ambulation training in addition to conventional overground walking, dependent on resource availability, context, and local expertise (low evidence); (3) We suggest that individuals with acute and subacute cervical SCI be offered functional electrical stimulation as an option to improve hand and upper extremity function (low evidence); and (4) Based on the absence of any clear benefit, we suggest not offering additional training in unsupported sitting beyond what is currently incorporated in standard rehabilitation (low evidence). Conclusions: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions.

scholarly journals Timing of Decompression in Patients With Acute Spinal Cord Injury: A Systematic Review

2017 ◽  
Vol 7 (3_suppl) ◽  
pp. 95S-115S ◽  
Author(s):  
Jefferson R. Wilson ◽  
Lindsay A. Tetreault ◽  
Brian K. Kwon ◽  
Paul M. Arnold ◽  
Thomas E. Mroz ◽  
...  
Keyword(s):  
Systematic Review ◽  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Surgical Decompression ◽  
Acute Spinal Cord Injury ◽  
Strength Of Evidence ◽  
Cord Injury ◽  
Central Cord Syndrome ◽  
Low Strength ◽  
The Impact

Study Design: Systematic review. Objective: To conduct a systematic review and synthesis of the literature to assess the comparative effectiveness, safety, and cost-effectiveness of early (≤24 hours) versus late decompression (>24 hours) in adults with acute spinal cord injury (SCI). Methods: A systematic search was conducted of Medline, EMBASE, the Cochrane Collaboration Library, and Google Scholar to identify studies published through November 6, 2014. Studies published in any language, in humans, and with an abstract were considered for inclusion. Included studies were critically appraised and the overall strength of evidence was determined using methods proposed by the Grading of Recommendation Assessment, Development and Evaluation working group. Results: The search yielded 449 potentially relevant citations. Sixteen additional primary studies were identified through other sources. Six studies met inclusion criteria. All but 2 studies were considered to have moderately high risk of bias. Across studies and injury levels, the impact of early surgical decompression (≤24 hours) on clinically important improvement in neurological status was variable. Isolated studies reported statistically significant and clinically important improvements at 6 months (cervical injury, low strength of evidence) and following discharge from inpatient rehabilitation (all levels, very low strength of evidence) but not at other time points; another study observed a statistically significant 6 point improvement in ASIA Impairment Scale (AIS) among patients with AIS B, C, or D, but not for those with AIS A (very low strength of evidence). In one study of acute central cord syndrome without instability, a clinically and statistically meaningful improvement in total motor scores was reported at 6 and 12 months in patients treated early (versus late). There were, however, no significant differences in AIS improvement between early and late surgical groups at 6- or 12-months (very low strength of evidence). One of 3 studies found a shorter length of hospital stay associated with early surgical decompression. Of 3 studies reporting on safety, no significant differences in rates of complications (including mortality, neurologic deterioration, pneumonia or pressure ulcers) were noted between early and late decompression groups. Conclusions: Results surrounding the efficacy of early versus late decompressive surgery, as well as the quality of evidence available, were variable depending on the level of SCI, timing of follow-up, and specific outcome considered. Existing evidence supports improved neurological recovery among cervical SCI patients undergoing early surgery; however, evidence regarding remaining SCI populations and clinical outcomes was inconsistent.

scholarly journals Early Versus Late Surgical Decompression for Acute Spinal Cord Injury: An Individual Patient Data Meta-Analysis of 1548 Patients

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Jetan H Badhiwala ◽  
Christopher D Witiw ◽  
Jefferson R Wilson ◽  
Michael G Fehlings
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Individual Patient Data ◽  
Meta Analysis ◽  
Surgical Decompression ◽  
Early Surgery ◽  
Light Touch ◽  
Surgery Group ◽  
Cord Injury ◽  
Sensorimotor Recovery

Abstract INTRODUCTION We sought to leverage the statistical power derived from pooling 4 high-quality prospective datasets to compare sensorimotor recovery with early (< 24 hr) vs late (≥ 24 hr) surgical decompression for acute traumatic spinal cord injury (SCI). METHODS Patients with acute SCI who underwent surgical decompression were identified from 4 prospective, multi-center SCI datasets (NACTN, STASCIS, Sygen, and NASCIS III). Patients were dichotomized into early (< 24 hr) and late (≥ 24 hr) surgery groups. The primary end point was change in ASIA motor score (AMS) at 1-yr. Secondary outcomes included AIS grade and change in ASIA light touch and pin prick scores at 1-yr. One-stage meta-analyses for each outcome were performed by hierarchical mixed-effects regression using a stratified intercept to account for clustering of patients within studies. Fixed-effect covariates were specified for baseline score, age, injury mechanism, AIS grade, neurological level, and steroids. The treatment (early vs late surgery) was specified as a random-effect. RESULTS A total of 1548 patients were eligible. The early surgery group experienced greater improvement than the late surgery group at 1-yr for AMS (MD 4.0, 95% CI 1.7-6.2, P = .001), light touch score (MD 4.6, 95% CI 1.9-7.2, P = .001), and pin prick score (MD 4.2, 95% CI 1.5-6.9, P = .003). Further, on ‘shift analysis’, the early surgery group achieved a more favorable distribution of AIS grades at 1-yr compared to the late surgery group (cOR 1.46, 95% CI 1.14-1.87, P = .003). The effect of early surgery was strongest for cervical SCI (P = .003); however, we observed a trend toward improved recovery with early versus late surgery for thoracic SCI as well (MD 5.2, 95% CI -0.8-11.2, P = .088). CONCLUSION In an individual patient data meta-analysis adjusting for potential confounders, we found early surgery, within 24 hr of injury, to be associated with superior sensorimotor recovery at 1-yr following acute SCI, as compared to late surgery.

scholarly journals Early Surgery for Traumatic Spinal Cord Injury: Where Are We Now?

2020 ◽  
Vol 10 (1_suppl) ◽  
pp. 84S-91S ◽  
Author(s):  
Jefferson R. Wilson ◽  
Christopher D. Witiw ◽  
Jetan Badhiwala ◽  
Brian K. Kwon ◽  
Michael G. Fehlings ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Injury Severity ◽  
Significant Proportion ◽  
Evidence Base ◽  
Narrative Review ◽  
Early Surgery ◽  
Traumatic Spinal Cord Injury ◽  
Cord Injury ◽  
Central Cord Syndrome

Study Design: Narrative review. Objective: There is a strong biological rationale to perform early decompression after traumatic spinal cord injury (SCI). With an enlarging clinical evidence base, most spine surgeons internationally now favor early decompression for the majority of SCI patients; however, a number of pertinent questions remain surrounding this therapy. Methods: A narrative review evaluating the status of early surgery for SCI. In particular, we addressed the following questions: (1) Which patients stand to benefit most from early surgery? 2) What is the most appropriate time threshold defining early surgery? Results: Although heterogeneity exists, the evidence generally seems to support early surgery. While the best evidence exists for cervical SCI, there is insufficient data to support a differential effect for early surgery depending on neurological level or injury severity. When comparing thresholds to define early versus late surgery—including a later threshold (48-72 hours), an earlier threshold (24 hours), and an ultra-early threshold (8-12 hours)—the 2 earlier time points seem to be associated with the greatest potential for improved outcomes. However, existing prehospital and hospital logistics pose barriers to early surgery in a significant proportion of patients. An overview of recommendations from the recent AOSpine guidelines is provided. Conclusion: In spite of increasing acceptance of early surgery post SCI, further research is needed to (1) identify subgroups of patients who stand to derive particular benefit—in particular to develop more evidence-based approaches for central cord syndrome and (2) investigate the efficacy and feasibility of ultra-early surgery targeting more aggressive timelines.

scholarly journals A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Use of Methylprednisolone Sodium Succinate

2017 ◽  
Vol 7 (3_suppl) ◽  
pp. 203S-211S ◽  
Author(s):  
Michael G. Fehlings ◽  
Jefferson R. Wilson ◽  
Lindsay A. Tetreault ◽  
Bizhan Aarabi ◽  
Paul Anderson ◽  
...  
Keyword(s):  
Systematic Review ◽  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Clinical Practice ◽  
Sodium Succinate ◽  
Acute Spinal Cord Injury ◽  
Adult Patients ◽  
High Dose ◽  
Methylprednisolone Sodium Succinate ◽  
Cord Injury

Introduction: The objective of this guideline is to outline the appropriate use of methylprednisolone sodium succinate (MPSS) in patients with acute spinal cord injury (SCI). Methods: A systematic review of the literature was conducted to address key questions related to the use of MPSS in acute SCI. A multidisciplinary Guideline Development Group used this information, in combination with their clinical expertise, to develop recommendations for the use of MPSS. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest.” Results: The main conclusions from the systematic review included the following: (1) there were no differences in motor score change at any time point in patients treated with MPSS compared to those not receiving steroids; (2) when MPSS was administered within 8 hours of injury, pooled results at 6- and 12-months indicated modest improvements in mean motor scores in the MPSS group compared with the control group; and (3) there was no statistical difference between treatment groups in the risk of complications. Our recommendations were: (1) “We suggest not offering a 24-hour infusion of high-dose MPSS to adult patients who present after 8 hours with acute SCI”; (2) “We suggest a 24-hour infusion of high-dose MPSS be offered to adult patients within 8 hours of acute SCI as a treatment option”; and (3) “We suggest not offering a 48-hour infusion of high-dose MPSS to adult patients with acute SCI.” Conclusions: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in SCI patients.

scholarly journals A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis

2017 ◽  
Vol 7 (3_suppl) ◽  
pp. 212S-220S ◽  
Author(s):  
Michael G. Fehlings ◽  
Lindsay A. Tetreault ◽  
Bizhan Aarabi ◽  
Paul Anderson ◽  
Paul M. Arnold ◽  
...  
Keyword(s):  
Systematic Review ◽  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Clinical Practice ◽  
Management Strategies ◽  
Cost Effective ◽  
Thromboembolic Events ◽  
Bleeding Events ◽  
Acute Period ◽  
Cord Injury

Introduction: The objective of this study is to develop evidence-based guidelines that recommend effective, safe and cost-effective thromboprophylaxis strategies in patients with spinal cord injury (SCI). Methods: A systematic review of the literature was conducted to address key questions relating to thromboprophylaxis in SCI. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest.” Results: Based on conclusions from the systematic review and expert panel opinion, the following recommendations were developed: (1) “We suggest that anticoagulant thromboprophylaxis be offered routinely to reduce the risk of thromboembolic events in the acute period after SCI;” (2) “We suggest that anticoagulant thromboprophylaxis, consisting of either subcutaneous low-molecular-weight heparin or fixed, low-dose unfractionated heparin (UFH) be offered to reduce the risk of thromboembolic events in the acute period after SCI. Given the potential for increased bleeding events with the use of adjusted-dose UFH, we suggest against this option;” (3) “We suggest commencing anticoagulant thromboprophylaxis within the first 72 hours after injury, if possible, in order to minimize the risk of venous thromboembolic complications during the period of acute hospitalization.” Conclusions: These guidelines should be implemented into clinical practice in patients with SCI to promote standardization of care, decrease heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.

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