SCI Guidelines 2013

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Introduction to the Guidelines for the Management

of Acute Cervical Spine and Spinal Cord Injuries

Medical evidence-based guidelines, whenproperly produced, represent a contem-porary scientific summary of accepted

management, imaging, assessment, classification,and treatment strategies on a focused series ofmedical and surgical issues.1-3 They are anevidence-based hierarchal ranking of the scien-tific literature produced to date. They record andrank the collective experiences of scientists andclinicians and are a comprehensive referencesource on a given topic or group of topics.

Medical evidence-based guidelines are notmeant to be restrictive or to limit a clinicianspractice. They chronicle multiple successfultreatment options (for example) and stratifythe more successful and the less successfulstrategies based on scientific merit. They arenot absolute, must be followed rules. Thisprocess may identify the most valid and reliableimaging strategy for a given injury, for example,but because of regional or institutional resources,or patient co-morbidity, that particular imagingstrategy may not be possible for a patient with

that injury. Alternative acceptable imagingoptions may be more practical or applicable inthis hypothetical circumstance.

Guidelines documents arenot tools to be usedby external agencies to measure or control thecare provided by clinicians. They are notmedical-legal instruments or a set of certain-ties that must be followed in the assessment ortreatment of the individual pathology in theindividual patients we treat. While a powerfuland comprehensive resource tool, guidelinesand the recommendations contained therein donot necessarily represent the answer for the

medical and surgical dilemmas we face with ourmany patients.

This second iteration of Guidelines for theManagement of Acute Cervical Spine and SpinalCord Injuries represents 15 months of diligentvolunteer effort by the Joint Section on Disordersof the Spine and Peripheral Nerves authorgroup to provide an up-to-date review of themedical literature on 22 topics germane to thecare, assessment, imaging and treatment of

patients with acute cervical spine and/or spinalcord injuries. The medical evidence summa-rized within each guideline has been painstak-ingly analyzed and ranked according to rigorousevidence-based medicine criteria, and have beenlinked to 112 evidence-based recommendationsfor these topics.1-3

There are many important differences in thisiteration of these Guidelines compared to thosewe published 10 years ago. Regrettably, how-ever, for some of the topics considered and

included in this medical evidence-based com-pendium, little new evidence beyond Class IIImedical evidence has been offered in the last 10years by investigators and surgeons who treatpatients with thesedisorders. Our specialties andour patients desperately need comparative ClassI and Class II medical evidence derived fromproperly designed analytical clinical studies tofurther our understanding on the best ways toassess, diagnose, image and treat patients withthese acute traumatic injuries.

Good progress has been made in several

clinical research areas since the original Guide-lines publication in 2002. One hundred twelveevidence-based recommendations are offeredin this contemporary review, compared toonly 76 recommendations in 2002. There are19 Level I recommendations in the currentGuidelines; each supported by Class I medicalevidence.

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 recom-mendations based on Class II medical evidenceand77 Level IIIrecommendations based on ClassIII medical evidence.

Mark N. Hadley, MD*

Beverly C. Walters, MD, MSc,

FRCSC

*Co-Lead Author, Guidelines Author

Group; Charles A. & Patsy W. Collat

Professor of Neurosurgery and Program

Director, University of Alabama Neurosur-

gical Residency Training Program, Division

of Neurological Surgery, University of

Alabama at Birmingham, Birmingham,

Alabama; Co-Lead Author, Guidelines

Author Group; Professor of Neurologi-cal Surgeryand Directorof ClinicalResearch,

University of Alabama at Birmingham,

Birmingham, Alabama; Professor of Neuro-

sciences, Virginia Commonwealth Univer-

sity - Inova Campus and Director of Clinical

Research, Department of Neurosciences,

Inova Health System, Falls Church, Virgin-

ia; Affiliate Professor of Molecular Neuro-

sciences,George Mason University, Fairfax,

Virginia

Copyright 2013 by the

Congress of Neurological Surgeons

INTRODUCTION

TOPIC INTRODUCTION

NEUROSURGERY VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT | 5

Co ri ht Con ress of Neurolo ical Sur eons. Unauthorized re roduction of this article is rohibited.


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TABLE. Comparison of Cervical Spine and Spinal Cord Injury Guidelines Recommendations Between 2 Iterations Where Differences in

Recommendations Have Occurred. All Other Recommendations Remain as Previously Stated

Topic

Previous

Level of

Recommendation Recommendation 2002

Current

Level of


Immobilization Option All trauma patients with a cervicalspinal column injury or witha mechanism of injury having thepotential to cause cervical spineinjury should be immobilized at thescene and during transport byusing 1 of several availablemethods.

Level II Spinal immobilization of all traumapatients with a cervical spine or spinalcord injury or with a mechanism ofinjury having the potential to causecervical spinal injury is recommended.

Triage of patients with potential spinalinjury at the scene by trained andexperienced EMS personnel todetermine the need for immobilizationduring transport is recommended.

A combination of a rigid cervicalcollar and supportive blocks ona backboard with straps is effectivein limiting motion of the cervicalspine and is recommended.

Immobilization of trauma patients whoare awake, alert, and are notintoxicated, who are without neck painor tenderness, who do not have anabnormal motor or sensoryexamination and who do not have anysignificant associated injury that mightdetract from their general evaluation isnot recommended.

None Not addressed Level III Spinal immobilization in patients withpenetrating trauma is notrecommended due to increasedmortality from delayed resuscitation.

Transportation None Not addressed Level III Whenever possible, the transport ofpatients with acute cervical spine or

spinal cord injuries to specialized acutespinal cord injury treatment centers isrecommended.

Clinical Assessment:Neurological status

Option The ASIA international standardsare recommended as the preferredneurological examination tool.

Level II New Class II medical evidence.

Clinical Assessment:Functional status

Guideline The Functional IndependenceMeasure is recommended as thefunctional outcome assessmenttool for clinicians involved in theassessment and care of patientswith acute spinal cord injuries.

Level I The Spinal Cord IndependenceMeasure (SCIM III) is recommended asthe preferred Functional OutcomeAssessment tool for clinicians involvedin the assessment, care, and follow-upof patients with spinal cord injuries.

Option The modified Barthel index isrecommended as a functional

outcome assessment tool forclinicians involved in theassessment and care of patientswith acute spinal cord injuries.

N.A. (Not includedin current

iteration)

N.A. (Not included incurrent iteration)

Clinical Assessment:Pain

None Not addressed Level I The International Spinal Cord InjuryBasic Pain Data Set (ISCIBPDS) isrecommended as the preferred meansto assess pain including pain severity,physical functioning and emotionalfunctioning among SCI patients.

(Continues)

HADLEYAND WALTERS

6 | VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT www.neurosurgery-online.com



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TABLE. Continued

Topic

Previous

Level of


Current

Level of


RadiographicAssessment:AsymptomaticPatient

Standard Radiographic assessment of thecervical spine is not recommendedin trauma patients who are awake,alert, and not intoxicated, who arewithout neck pain or tenderness,and who do not have significantassociated injuries that detractfrom their general evaluation.

Level I In the awake, asymptomatic patientwho is without neck pain ortenderness, who has a normalneurological examination, is withoutan injury detracting from an accurateevaluation, and who is able tocomplete a functional range of motionexamination; radiographic evaluationof the cervical spine is notrecommended.

Discontinuance of cervicalimmobilization for these patients isrecommended without cervical spinalimaging.

Option

It is recommended that cervicalspine immobilization in awakepatients with neck pain ortenderness and normal cervicalspine x-rays (includingsupplemental CT as necessary) bediscontinued after wither a) normaland adequate dynamic flexion/extension radiographs, or b)a normal magnetic resonanceimaging study is obtained within48 hours of injury.

Level III

In the awake patient with neck pain ortenderness and normal high-quality CTimaging or normal 3-view cervicalspine series (with supplemental CT ifindicated), the followingrecommendations should beconsidered:

1) Continue cervical immobilization untilasymptomatic,

2) Discontinue cervical immobilizationfollowing normal and adequate dynamicflexion/extension radiographs,

3) Discontinue cervical immobilizationfollowing a normal MRI obtained within48 hours of injury (limited andconflicting Class II and Class III medicalevidence), or,

Cervical spine immobilization inobtunded patients with normalcervical spine x-rays (includingsupplemental CT as necessary) maybe discontinued a after dynamicflexion/extension studiesperformed under fluoroscopic

guidance, or b) after a normalmagnetic resonance imaging studyis obtained within 48 hours ofinjury, or c at the discretion of thetreating physician.

4) Discontinue cervical immobilization atthe discretion of the treating physician.

(Continues)

INTRODUCTION




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TABLE. Continued

Topic

Previous

Level of


Current

Level of


RadiographicAssessment:SymptomaticPatient

Standard A 3-view cervical spine series(anteroposterior, lateral, andodontoid views) is recommendedfor radiographic evaluation of thecervical spine in patients who aresymptomatic after traumatic injury.This should be supplemented withcomputed tomography (CT) tofurther define areas that aresuspicious or not well visualized onthe plain cervical x-rays.

Level I In the awake, symptomatic patient,high-quality computed tomographic(CT) imaging of the cervical spine isrecommended.

If high-quality CT imaging is available,routine 3-view cervical spineradiographs are not recommended.

If high-quality CT imaging is notavailable, a 3 view cervical spine series(AP, lateral, and odontoid views) isrecommended. This should besupplemented with CT (when itbecomes available) if necessary tofurther define areas that are suspiciousor not well visualized on the plaincervical x-rays.

Option It is recommended that cervicalspine immobilization in awakepatients with neck pain ortenderness and normal cervicalspine x-rays (includingsupplemental CT as necessary) bediscontinued after either a) normaland adequate dynamic flexion/extension radiographs, or b)a normal magnetic resonanceimaging study is obtained within48 hours of injury.

Level III In the awake patient with neck pain ortenderness and normal high-quality CTimaging or normal 3-view cervicalspine series (with supplemental CT ifindicated), the followingrecommendations should beconsidered:

1) Continue cervical immobilization untilasymptomatic,

2) Discontinue cervical immobilizationfollowing normal and adequate dynamicflexion/extension radiographs,

3) Discontinue cervical immobilizationfollowing a normal MRI obtained within48 hours of injury (limited and

conflicting Class II and Class III medicalevidence), or,

4) Discontinue cervical immobilization atthe discretion of the treating physician.

(Continues)

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TABLE. Continued

Topic

Previous

Level of


Current

Level of


Radiographicevaluation inobtunded (orunevaluable)patients

Option Cervical spine immobilization inobtunded patients with normalcervical spine x-rays (includingsupplemental CT as necessary) maybe discontinued a) after dynamicflexion/extension studiesperformed under fluoroscopicguidance, or b) after a normalmagnetic resonance imaging studyis obtained within 48 hours ofinjury, or c) at the discretion of thetreating physician.

Level I In the obtunded or un-evaluablepatient, high-quality CT imaging isrecommended as the initial imagingmodality of choice. If CT imaging isavailable, routine 3-view cervical spineradiographs are not recommended.

If high-quality CT imaging is notavailable, a 3 view cervical spine series

(AP, lateral, and odontoid views) isrecommended. This should besupplemented with CT (when itbecomes available) if necessary tofurther define areas that are suspiciousor not well visualized on the plaincervical x-rays.

Closed Reduction Option Early closed reduction isrecommended.

Level III No changes in recommendations

CardiopulmonaryManagement

Option Management of patients with acuteSCI in a monitored setting isrecommended.


Maintain mean arterial BP 85 to 90mm Hg after SCI is recommended.

Pharmacology

Management:Corticosteroids

Option Treatment with

methylprednisolone for either 24or 48 hours is recommended as anoption in the treatment of patientswith acute spinal cord injuries thatshould be undertaken only withthe knowledge that the evidencesuggesting harmful side effects ismore consistent than anysuggestion of clinical benefit.

Level I Administration of methylprednisolone

(MP) for the treatment of acute SCI isnot recommended. Cliniciansconsidering MP therapy should bear inmind that the drug is not FDAapproved for this application. There isno Class I or Class II medical evidencesupporting the clinical benefit of MP inthe treatment of acute SCI. Scatteredreports of Class III evidence claiminconsistent effects likely related torandom chance or selection bias.However, Class I, II, and III evidenceexists that high-dose steroids areassociated with harmful side effectsincluding death.

PharmacologyManagement: GM-1Ganglioside

Option Treatment of patients with acutespinal cord injuries with GM-1ganglioside is recommended as anoption without demonstratedclinical benefit.

Level I Administration of GM-1 ganglioside(Sygen) for the treatment of acute SCIis not recommended.

Occipital CondylarFractures:Diagnostic

Guidelines (CT) CT recommended to diagnose OCF. Level II (CT) No changes in recommendation

Option (MRI) MRI recommended to assessligaments.

Level III (MRI)

(Continues)

INTRODUCTION




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TABLE. Continued

Topic

Previous

Level of


Current

Level of


Occipital CondylarFractures: Treatment

Option Treatment with external cervicalimmobilization is recommended.

Level III External cervical immobilization isrecommended for all types of occipitalcondyle fractures.

More rigid external immobilization ina halo vest device should beconsidered for bilateral OCF.

Halo vest immobilization oroccipitocervical stabilization andfusion are recommended for injurieswith associated AO ligamentous injuryor evidence of instability.

AOD: Diagnostic None Not addressed Level I CT imaging to determine the CCI inpediatric patients with potential AODis recommended.

Option If there is clinical suspicion ofatlanto-occipital dislocation, andplain x-rays are non-diagnostic,computed tomography ormagnetic resonance imaging isrecommended, particularly for thediagnosis of non-Type IIdislocations.

Level III If there is clinical or radiographicsuspicion of AOD, and plainradiographs are non-diagnostic, CT ofthe craniocervical junction isrecommended. The Condyle-C1interval (CC1) determined on CT hasthe highest diagnostic sensitivity andspecificity for AOD among allradiodiagnostic indicators.

AOD: Treatment Option Traction may be used in themanagement of patients withatlanto-occipital dislocation, but itis associated with a 10% risk ofneurological deterioration.

Level III Traction is not recommended in themanagement of patients with AOD,and is associated with a 10% risk ofneurological deterioration.

Atlas Fractures Option Treatment based on specificfracture type and integrity oftransverse ligament.


Odontoid Fracture Guideline Treatment of Type II odontoidfractures based on 50 years of age.

Level II No change in recommendations

Axis Fractures:Odontoid

None Not addressed Level III If surgical stabilization is elected, eitheranterior or posterior techniques arerecommended.

Axis Fractures:Hangmans

Option External immobilization isrecommended.


Surgery is recommended forangulation, instability.

Axis Fractures:Miscellaneous Body

Option External immobilization isrecommended for treatment ofisolated fractures of the axis body.

Level III External immobilization for thetreatment of isolated fractures of theaxis body is recommended.

Consideration of surgical stabilizationand fusion in unusual situations ofsevere ligamentous disruption and/orinability to achieve or maintain fracturealignment with externalimmobilization is recommended.

In the presence of comminutedfracture of the axis body, evaluation forvertebral artery injury isrecommended.

(Continues)

HADLEYAND WALTERS




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TABLE. Continued

Topic

Previous

Level of


Current

Level of


Atlas/AxisCombinationFractures

Option Treatment based on characteristicsof axis fracture.


Os Odontoideum:Diagnostic

Option Plain radiographs with flex/ext 6CT or MRI is recommended.


Os Odontoideum:Management

Option Occipital-cervical fusion with orwithout C1 laminectomy may beconsidered in patients with osodontoideum who have irreducibledorsal cervicomedullarycompression and/or evidence ofassociated occipital-atlantalinstability. Transoraldecompression may be considered

in patients with os odontoideumwho have irreducible ventralcervicomedullary compression.

Level III Occipital-cervical internal fixation andfusion with or without C1 laminectomyis recommended in patients with osodontoideum who have irreducibledorsal cervicomedullary compressionand/or evidence of associatedoccipital-atlantal instability.

Ventral decompression should beconsidered in patients with osodontoideum who have irreducibleventral cervicomedullary compression.

Classification ofSubaxial Injuries

None Not addressed Level I SLIC and CSISS

Level III Harris and AllenSubaxial Cervical

Spinal InjuriesNone Not addressed Level III The routine use of CT and MR imaging

of trauma victims with ankylosingspondylitis is recommended, even afterminor trauma.

For patients with ankylosingspondylitis who require surgicalstabilization, posterior long segmentinstrumentation and fusion, ora combined dorsal and anteriorprocedure is recommended. Anteriorstand-alone instrumentation andfusion procedures are associated witha failure rate of up to 50% in thesepatients.

Central CordSyndrome

Option Aggressive multimodalitymanagement of patients withATCCS is recommended.


Pediatric Injuries:Diagnostic

None Not addressed Level I CT imaging to determine the condyle-C1 interval for pediatric patients with

potential AOD is recommended.Guideline In children who have experienced

trauma and are alert, conversant,have no neurological deficit, nomidline cervical tenderness, and nopainful distracting injury, and arenot intoxicated, cervical spine x-rays are not necessary to excludecervical spine injury and are notrecommended.

Level II Cervical spine imaging is notrecommended in children who aregreater than 3 years of age and whohave experienced trauma and who:

(Continues)

INTRODUCTION




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TABLE. Continued

Topic

Previous

Level of


Current

Level of


In children who have experiencedtrauma and who are either notalert, non-conversant, or haveneurological deficit, midlinecervical tenderness, or painfuldistracting injury, or areintoxicated, it is recommended thatanteroposterior and lateral cervicalspine x-rays be obtained.

1) are alert,2) have no neurological deficit,3) have no midline cervical tenderness,4) have no painful distracting injury,5) do not have unexplained hypotension,6) and are not intoxicated. Cervical spine imaging is not

recommended in children who are lessthan 3 years of age who haveexperienced trauma and who:

1) have a GCS.13,2) have no neurological deficit,3) have no midline cervical tenderness,4) have no painful distracting injury,5) are not intoxicated,6) do not have unexplained hypotension,7) and do not have motor vehicle collision

(MVC),8) a fall from a height greater than 10 feet,9) or non-accidental trauma (NAT) as

a known or suspected mechanism ofinjury.

Cervical spine radiographs or highresolution computed tomography (CT)is recommended for children who haveexperienced trauma and who do notmeet either set of criteria above.

Three-position CT with C1-C2 motionanalysis to confirm and classify thediagnosis is recommended for childrensuspected of having atlanto-axialrotatory fixation (AARF).

Options In children younger than age 9years who have experienced

trauma, and who are non-conversant or haven an alteredmental status, a neurologicaldeficit, neck pain, or painfuldistracting injury, are intoxicated,or have unexplained hypotension,it is recommended thatanteroposterior and lateral cervicalspine x-rays be obtained.

Level III AP and lateral cervical spineradiography or high-resolution CT is

recommended to assess the cervicalspine in children less than 9 years ofage.

(Continues)

HADLEYAND WALTERS




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TABLE. Continued

Topic

Previous

Level of


Current

Level of


In children age 9 years or older whohave experienced trauma, and whoare non-conversant or have analtered mental status,a neurological deficit, neck pain, orpainful distracting injury, areintoxicated, or have unexplainedhypotension, it is recommendedthat anteroposterior, lateral, andopen-mouth cervical spine x-raysbe obtained.

AP, lateral, and open-mouth cervicalspine radiography or high-resolutionCT is recommended to assess thecervical spine in children 9 years of ageand older.

Computed tomographic scanningwith attention to the suspectedlevel of neurological injury toexclude occult fractures or toevaluate regions not seenadequately on plain x-rays isrecommended.

High resolution CT scan with attentionto the suspected level of neurologicalinjury is recommended to excludeoccult fractures or to evaluate regionsnot adequately visualized on plainradiographs.

Flexion/extension cervical x-rays orfluoroscopy may be considered toexclude gross ligamentousinstability when there remainsa suspicion of cervical spineinstability after static x-rays areobtained.

Flexion and extension cervicalradiographs or fluoroscopy arerecommended to exclude grossligamentous instability when thereremains a suspicion of cervical spinalinstability following static radiographsor CT scan.

Magnetic resonance imaging of thecervical spine may be considered toexclude cord or nerve rootcompression, evaluate ligamentous

integrity, or provide informationregarding neurological prognosis.

Magnetic resonance imaging (MRI) ofthe cervical spine is recommended toexclude spinal cord or nerve rootcompression, evaluate ligamentous

integrity, or provide informationregarding neurological prognosis.

Pediatric Injuries:Treatment

None Not addressed Level III Reduction with manipulation or haltertraction is recommended for patientswith acute AARF (less than 4 weeksduration) that does not reducespontaneously. Reduction with halteror tong/halo traction is recommendedfor patients with chronic AARF (greaterthan 4 weeks duration).

Internal fixation and fusion arerecommended in patients withrecurrent and/or irreducible AARF.

Operative therapy is recommended for

cervical spine injuries that fail non-operative management.

SCIWORA: Diagnosis Option Plain spinal x-rays of the region ofinjury and computed tomographicscanning with attention to thesuspected level of neurologicalinjury to exclude occult fracturesare recommended.

Level III Magnetic resonance imaging (MRI) ofthe region of suspected neurologicalinjury is recommended in a patientwith SCIWORA.

(Continues)

INTRODUCTION




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TABLE. Continued

Topic

Previous

Level of


Current

Level of


Magnetic resonance imaging of theregion of suspected neurologicalinjury may provide usefuldiagnostic information

Radiographic screening of the entirespinal column is recommended.

Plain X-rays of the entire spinalcolumn may be considered.

Assessment of spinal stability ina SCIWORA patient is recommended,using flexion-extension radiographs inthe acute setting and at late follow-up,even in the presence of a MRI negativefor extra-neural injury.

SCIWORA: Treatment Option External Immobilization isrecommended until spinal stabilityis confirmed by flexion/extensionx-rays.

Level III External immobilization of the spinalsegment of injury is recommended forup to 12 weeks.

External immobilization of the spinalsegment of injury for up to 12 weeksmay be considered.

Early discontinuation of externalimmobilization is recommended forpatients who become asymptomaticand in whom spinal stability isconfirmed with flexion and extensionradiographs.

Avoidance of high risk activitiesfor up to 6 months after spinal cordinjury without radiographicabnormality may be considered.

Avoidance of high-risk activities forup to 6 months following SCIWORA isrecommended.

SCIWORA: Prognosis Option Magnetic resonance imaging of theregion of neurological injury mayprovide useful prognosticinformation about neurologicaloutcome after spinal cord injurywithout radiographic abnormality.

None Not addressed (see Diagnosis)

Vertebral Artery Injury:Diagnostic

Option Conventional angiography ormagnetic resonance angiographyis recommended for the diagnosisof vertebral artery injury afternonpenetrating cervical trauma inpatients who have completecervical spinal cord injuries,fracture through the foramentransversarium, facet dislocation,and/or vertebral subluxation.

Level I Computed tomographic angiography(CTA) is recommended as a screeningtool in selected patients after bluntcervical trauma who meet themodified Denver Screening Criteria forsuspected vertebral artery injury (VAI).

Level III Conventional catheter angiography isrecommended for the diagnosis of VAI inselected patients after blunt cervical

trauma, particularly if concurrentendovascular therapy is a potentialconsideration, and can be undertaken incircumstances in which CTA is notavailable.

Magnetic resonance imaging isrecommended for the diagnosis of VAIafter blunt cervical trauma in patientswith a complete spinal cord injury orvertebral subluxation injuries.

(Continues)

HADLEYAND WALTERS




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The Table shows the differences in the recommendationsbetween the 2 sets of guidelines. One key change is that innomenclature: Standards has been replaced by Level I,Guidelines has been replaced by Level II, and Optionshas been replaced by Level III, as described in detail in theMethodology section of these guidelines. Not every recommen-dation is listed since some have not changed, and the statementNo changes in recommendations indicates that. When they have

changed, the recommendations previously made are compared tothose being made currently. Where we have introduced newrecommendations not included in the previous iteration of theguidelines, a statement is found indicating what the recommen-dations are alongside None and Not addressed, whichrepresents the lack of previous recommendations on a particularaspect or topic. This summary table highlighting the changes in theguidelines is not a substitute for reading and understanding this

TABLE. Continued

Topic

Previous

Level of


Current

Level of


Vertebral Artery Injury:Treatment

Option Anticoagulation with intravenousheparin is recommended forpatients with vertebral artery injurywho have evidence of posteriorcirculation stroke.

Level III It is recommended that the choice oftherapy for patients with VAI,anticoagulation therapy vs antiplatelettherapy vs no treatment, beindividualized based on the patientsvertebral artery injury, their associatedinjuries and their risk of bleeding.

Either observation or treatmentwith anticoagulation in patientswith vertebral artery injuries andevidence of posterior circulationischemia is recommended.

The role of endovascular therapy in VAIhas yet to be defined; therefore norecommendation regarding its use inthe treatment of VAI can be offered.

Observation in patients withvertebral artery injuries and no

evidence of posterior circulationischemia is recommended.

VenousThromboembolism:Prophylaxis

None Not addressed Level II Early administration of VTE prophylaxis(within 72 hours) is recommended.

Option Vena cava filters are recommendedfor patients who do not respond toanticoagulation or who are notcandidates for anticoagulationtherapy and/or mechanical devices.

Level III Vena cava filters are not recommendedas a routine prophylactic measure, butare recommended for select patientswho fail anticoagulation or who are notcandidates for anticoagulation and/ormechanical devices.

Nutritional Support Option Nutritional support of patients withspinal cord injuries isrecommended. Energy expenditure

is best determined by indirectcalorimetry in these patientsbecause equation estimates ofenergy expenditure andsubsequent caloric need tend to beinaccurate.

Level II Indirect calorimetry as the best meansto determine the caloric needs ofspinal cord injury patients is

recommended.

Level III Nutritional support of SCI patients isrecommended as soon as feasible. Itappears that early enteral nutrition(initiated within 72 hours) is safe, buthas not been shown to affectneurological outcome, the length ofstay or the incidence of complicationsin patients with acute SCI.

INTRODUCTION




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new version of the recommendations that reviews and evaluatesextant literature in detail.

This comprehensive guidelines update does not contain anevidence-based summary or recommendation on several topicsimportant to the care of our patients, our profession, and our

disciplines, simply because thereis not enough definitive medicalevidence in the literature on those topics to allow such a review.Emerging science in the repair and regeneration of spinal cordinjuries,4 emerging technology in imaging, the use of electro-physiological monitoring during surgery for spinal cord injury,new engineering technology in surgical implants,5 hypothermiain the care of the spinal cord injured patient6 and new scienceon the issue of the timing of surgery after acute traumaticcervical spinal injury,7,8 are examples of topics we simply do nothave enough meaningful or convincing medical evidence in ourliterature to be included in this scientific review of acute cervicalspine and spinal cord injuries.

The author group and the Joint Section leadership hope that

these guidelines will serve their intended valuable purpose. Theissues addressed in this scientific compendium are germane to theassessment, management, treatment, and study of the growingpopulation of acute traumatic cervical spine and spinal cord injurypatients we see daily in our practices. These patients, their injuries,their care, andin many cases, their losses, personally andto society,

are a major and growing societal and healthcare burden in theUnited States and around the world.9

REFERENCES

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

ProgramCommittee to Advise the Public Health Service on Clinical PracticeGuidelines: 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 ofNeurological Surgeons Annual Meeting; 2008; Denver, CO.

8. Fehlings MG, Wilson JR. Timing of surgical intervention in spinal trauma: what doesthe 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.

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