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Guidelines for the management of acute cervical spine and spinal cord injuries neurosurgery supplement march 2013

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Guidelines for the management of acute cervical spine and spinal cord injuries neurosurgery supplement march 2013

  1. 1. FOREWORD TOPIC FOREWORD ODaniel K. Resnick, MD n behalf of the AANS/CNS Joint Guide- reserve? Is the evidence for benefit really strong lines Committee, I am pleased to intro- enough to warrant the risk in an individualUniversity of Wisconsin School of Med-icine and Public Health, Department of duce the updated Guidelines for the patient? What about routine imaging for vertebralNeurosurgery, Madison, Wisconsin Management of Acute Cervical Spine and Spinal artery injuries—how many asymptomatic patients Cord Injury. This work describes the “state of the need to be exposed to radiation and potentiallyCorrespondence: literature” with regard to the treatment of patients anticoagulated for radiographic findings that mayDaniel K. Resnick, MD,University of Wisconsin School of with cervical spine and spinal cord injuries and is or may not have clinical importance? TheseMedicine and Public Health, a useful guide to help clinicians make important decisions cannot be made by a writing panel,Department of Neurosurgery, decisions in the care of these patients. As with all no matter how expert—they require “boots on the600 Highland Avenue, evidence-based guidelines, recommendations made ground” judgment, often made with incompleteMadison, WI 53792.E-mail: resnick@neurosurg.wisc.edu cannot exceed the strength of the literature, and information. Guidelines provide the best evi- where there is a lack of evidence or disagreement in dence, but only the evidence that exists. the literature, strong recommendations cannot be Additionally, application of guidelines needs toCopyright ª 2013 by the made. These recommendations represent a foun- be mitigated by patient desires when such desiresCongress of Neurological Surgeons dation for one leg of the “three-legged stool” of can be assessed. A decision regarding collar vs halo evidence-based practice. Having a well-described vs surgical immobilization of odontoid fractures and vetted summary of the available medical may be substantially guided by patient-related evidence helps to structure decisions also depen- factors and preferences—the same radiographic dent upon clinical judgment and patient desires. fracture may be treated differently depending on In some cases, the guidelines can provide firm patient age, community, and preference. and easily applicable guidance—the (non)use of This update of the Guidelines for the Management steroids is an example of such a recommendation of Acute Cervical Spine and Spinal Cord Injury is an in this volume. The authors present a compelling impressive accomplishment. The evolution of skill case from high-quality clinical studies demon- in evidence-based review in neurosurgery is evident strating a greater propensity for such medication throughout the document, as every process has to harm rather than benefit patients with spinal been improved over the last decade. The authors cord injuries. In most cases, however, the use of have not only updated the guidelines based on new guidelines requires further reflection. Application literature, but they have improved the applicability of clinical judgment to the use of guidelines begins of the guidelines to clinical practice through better with the determination of whether a guideline question formulation, illustrated graphically the applies to your patient. For example, fracture evolution of evidence to allow readers to appreciate patterns at the craniocervical junction may be what has been learned over the past decade, and complex, may be influenced by congenital abnor- incorporated a more sophisticated discussion of the malities, and may not fit into the neat boxes literature to explain areas of continued uncertainty. selected by the authors for classification. Similarly, The reader is encouraged to critically read the application of clinical practice guidelines needs to supporting evidence for the recommendations in be balanced against the cost of the application—is order to appreciate the context of the recommen- aggressive blood pressure augmentation appropri- dations as well as the limitations. The authors are ate for an elderly patient with limited cardiac congratulated on an outstanding piece of work.NEUROSURGERY VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT | 1 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  2. 2. COMMENTARY TOPIC COMMENTARY TCopyright ª 2013 by the hese revised guidelines are an outstanding designated specialty care centers (ie, “we canCongress of Neurological Surgeons achievement, and neurosurgeons should be do it better so you should send all your cases proud of these authors who have taken the to us”). time and effort to create this work. Overall, the Finally, the summary Table in the introduc- methodology is sound and the results are solid. I tion is incomplete. It lists many of the recom- congratulate the authors for not being tempted to mendations listed in this volume but does not list comment on popular but yet inadequately stud- all of them. A complete and comprehensive ied topics such as hypothermic treatment of acute tabulation of all the recommendations would be spinal cord injury just because this topic appears very helpful. in the newspapers. Jeffrey W. Cozzens Some of the recommendations in this volume Springfield, Illinois are repeated in different chapters. For example, the first two recommendations in the paper on In this newest edition of the Guidelines for the the management of acute traumatic central cord Management of Acute Cervical Spine and Spinal syndrome (ATCCS) are also found in the paper Cord Injury, the author group has updated the dealing with cardio-pulmonary management of 2002 guidelines in a number of ways, incor- spinal cord injury. porating the newest available studies as well as The paper on transportation of patients with scrutinizing existing studies. The review process acute traumatic cervical spine injuries raises some for this edition has included additional review interesting policy questions for providers. In this by the AANS/CNS Joint Guidelines Commit- paper, the second recommendation is that, tee, and this has prompted several refinements whenever possible, patients with acute cervical of the recommendations that have resulted in spine or spinal cord injuries be transported to a work that is very tightly tied to the available specialized acute spinal cord injury treatment evidence in the literature. Features such as centers. But what makes an institution a “specialized a summary of changes between the two sets of acute spinal cord injury treatment center”? Are guidelines, and evidence tables that are easy to these centers designated by a governmental agency/ cross-reference with text and recommendations regulatory body, or are they self-designated? If the make this edition more accessible than ever answer is that an acute spinal cord injury center is before. any institution that can provide acute critical care As a community neurosurgeon, it can some- and surgical care, then isn’t it the care itself that is times be difficult to glean practical rules from important and not the designation of the many of the EBM practice guidelines currently institution? available; I believe this set will be an aid not only to What about care of the acute spinal cord injury academicians and those with backgrounds in patient that is provided within all the recommen- epidemiology and evidence-based medicine, but dations for critical care and surgical care published also to the vast majority of neurosurgeons who are in these guidelines but provided in an institution extremely skilled in patient care and who look to that does not choose to call itself an “acute spinal these types of published practice guidelines for cord injury treatment center”? Is the care changes in current thinking about what is—and is inadequate because of the lack of designation or not—supported in the neurosurgical literature. recognition? This is not a trivial issue from The more accessible and transparent these guide- a medical-legal standpoint. lines efforts are, the more readily they will be There is a concern shared by a number of embraced both by our colleagues in neurosurgery healthcare providers that a recommendation and well as in other disciplines, including like the second recommendation in this par- emergency medicine and trauma surgery; the ticular paper is the result of a conflict of interest use of the same sets of guidelines by multiple from large medical centers that are often self- specialties will surely foster better communication2 | VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT www.neurosurgery-online.com Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  3. 3. COMMENTARYand collaboration in the care of many patients. The author group investigated topics. Although this table is handy and informative,should be congratulated on another excellent effort. the reader should not use this as a substitute for reading the individual chapters in detail, as the material provided allows for J. Adair Prall a better understanding of the genesis of the recommendations. Littleton, Colorado All of the topics are thoroughly investigated and presented, yet I In recent years, there has been a growing national interest in must make special mention of the chapter entitled “Pharmaco-enhancing the quality of patient care. One of the commonly used logical Therapy for Acute Spinal Cord Injury.” The use ofmethods is standardization, which has been associated with steroids in acute SCI is a very controversial subject, withincreased quality of care in various health care settings. In the practitioners falling on either side of the treatment line. Tosetting of spinal trauma, rigid standardization is frequently many, the literature has previously lacked clarity on this subject.impractical and difficult, as there are often subtle differences One of the few criticisms of the 2002 guidelines is that the role ofbetween patient characteristics, injury patterns, and other clinical methylprednisolone was not clearly defined: “Treatment withconsiderations that may result in two similarly presenting methylprednisolone for either 24 or 48 hours is recommended aspatients receiving different, yet appropriate treatment. Another an option in the treatment of patients with acute spinal cordmethod to enhance quality is to provide practitioners with injuries...” The present day usage of methylprednisolone is fueledfactual, evidenced-based information that may validate estab- by both a desire to do everything humanly possible for theselished consensus opinion, or, in some cases, may even shift tragically injured patients, as well as medicolegal concerns, whichtreatment paradigms. The 2012 Guidelines for the Management can be quite significant in some communities. The 2012of Acute Cervical Spine and Spinal Cord Injury is likely to guidelines clearly state that methylprednisolone is not recom-improve the quality of patient care through both mechanisms. mended in the management of acute SCI, and that there is no Students of the 2002 Guidelines for the Management of Acute Class I or II evidence to support its use. In stark contrast, there isCervical Spine and Spinal Cord Injury will be very pleased with the Class I–III evidence that this treatment is associated with harmfulcurrent offering. The present rendition provides a balanced, side effects. This powerful and well-written chapter will provideevidenced-based assessment of the available literature regarding an immediate and beneficial impact on patient care.a broad swath of management strategies ranging from underap- The authors should be congratulated for their excellent work.preciated topics such as the transportation of acute SCI patients, This was an arduous and challenging task that was completed in anto more provocative subjects such as the use of steroids in acute elegant and outstanding fashion.spinal injury. The authors provide an easy to use table that Langston Hollycontrasts the 2002 and 2012 recommendations for each of the Los Angeles, CaliforniaNEUROSURGERY VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT | 3 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  4. 4. GUIDELINES COMMITTEE TOPIC Guidelines Committee4 | VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT www.neurosurgery-online.com Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  5. 5. INTRODUCTION TOPIC INTRODUCTION Introduction to the Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries M edical evidence-based guidelines, when patients with acute cervical spine and/or spinalMark N. Hadley, MD* properly produced, represent a contem- cord injuries. The medical evidence summa-Beverly C. Walters, MD, MSc, porary scientific summary of accepted rized within each guideline has been painstak-FRCSC‡ management, imaging, assessment, classification, ingly analyzed and ranked according to rigorous*Co-Lead Author, Guidelines Author and treatment strategies on a focused series of evidence-based medicine criteria, and have beenGroup; Charles A. & Patsy W. Collat medical and surgical issues.1-3 They are an linked to 112 evidence-based recommendationsProfessor of Neurosurgery and Program evidence-based hierarchal ranking of the scien- for these topics.1-3Director, University of Alabama Neurosur- tific literature produced to date. They record and There are many important differences in thisgical Residency Training Program, Divisionof Neurological Surgery, University of rank the collective experiences of scientists and iteration of these Guidelines compared to thoseAlabama at Birmingham, Birmingham, clinicians and are a comprehensive reference we published 10 years ago. Regrettably, how-Alabama; ‡Co-Lead Author, Guidelines source on a given topic or group of topics. ever, for some of the topics considered andAuthor Group; Professor of Neurologi-cal Surgery and Director of Clinical Research, Medical evidence-based guidelines are not included in this medical evidence-based com-University of Alabama at Birmingham, meant to be restrictive or to limit a clinician’s pendium, little new evidence beyond Class IIIBirmingham, Alabama; Professor of Neuro- practice. They chronicle multiple successful medical evidence has been offered in the last 10sciences, Virginia Commonwealth Univer-sity - Inova Campus and Director of Clinical treatment options (for example) and stratify years by investigators and surgeons who treatResearch, Department of Neurosciences, the more successful and the less successful patients with these disorders. Our specialties andInova Health System, Falls Church, Virgin- strategies based on scientific merit. They are our patients desperately need comparative Classia; Affiliate Professor of Molecular Neuro- I and Class II medical evidence derived fromsciences, George Mason University, Fairfax, not absolute, “must be followed” rules. ThisVirginia process may identify the most valid and reliable properly designed analytical clinical studies to imaging strategy for a given injury, for example, further our understanding on the best ways to but because of regional or institutional resources, assess, diagnose, image and treat patients withCopyright ª 2013 by the or patient co-morbidity, that particular imaging these acute traumatic injuries.Congress of Neurological Surgeons strategy may not be possible for a patient with Good progress has been made in several that injury. Alternative acceptable imaging clinical research areas since the original Guide- options may be more practical or applicable in lines publication in 2002. One hundred twelve this hypothetical circumstance. evidence-based recommendations are offered Guidelines documents are not tools to be used in this contemporary review, compared to by external agencies to measure or control the only 76 recommendations in 2002. There are care provided by clinicians. They are not 19 Level I recommendations in the current medical-legal instruments or a “set of certain- Guidelines; each supported by Class I medical ties” that must be followed in the assessment or evidence. treatment of the individual pathology in the • Assessment of Functional Outcomes (1) individual patients we treat. While a powerful • Assessment of Pain After Spinal Cord and comprehensive resource tool, guidelines Injuries (1) and the recommendations contained therein do • Radiographic Assessment (7) not necessarily represent “the answer” for the • Pharmacology (2) medical and surgical dilemmas we face with our • Diagnosis of AOD (1) many patients. • Cervical Subaxial Injury Classification This second iteration of Guidelines for the Schemes (2) Management of Acute Cervical Spine and Spinal • Pediatric Spinal Injuries (1) Cord Injuries represents 15 months of diligent • Vertebral Artery Injuries (1) volunteer effort by the Joint Section on Disorders • Venous Thromboembolism (3) of the Spine and Peripheral Nerves author There are an additional 16 Level II recom- group to provide an up-to-date review of the mendations based on Class II medical evidence medical literature on 22 topics germane to the and 77 Level III recommendations based on Class care, assessment, imaging and treatment of III medical evidence.NEUROSURGERY VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT | 5 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  6. 6. HADLEY AND WALTERS 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 Previous Current Level of Level of Topic Recommendation Recommendation 2002 Recommendation Recommendation 2012 Immobilization Option • All trauma patients with a cervical Level II • Spinal immobilization of all trauma spinal column injury or with patients with a cervical spine or spinal a mechanism of injury having the cord injury or with a mechanism of potential to cause cervical spine injury having the potential to cause injury should be immobilized at the cervical spinal injury is recommended. scene and during transport by using 1 of several available methods. • Triage of patients with potential spinal injury at the scene by trained and experienced EMS personnel to determine the need for immobilization during transport is recommended. • A combination of a rigid cervical • Immobilization of trauma patients who collar and supportive blocks on are awake, alert, and are not a backboard with straps is effective intoxicated, who are without neck pain in limiting motion of the cervical or tenderness, who do not have an spine and is recommended. abnormal motor or sensory examination and who do not have any significant associated injury that might detract from their general evaluation is not recommended. None Not addressed Level III • Spinal immobilization in patients with penetrating trauma is not recommended due to increased mortality from delayed resuscitation. Transportation None Not addressed Level III • Whenever possible, the transport of patients with acute cervical spine or spinal cord injuries to specialized acute spinal cord injury treatment centers is recommended. Clinical Assessment: Option • The ASIA international standards Level II • New Class II medical evidence. Neurological status are recommended as the preferred neurological examination tool. Clinical Assessment: Guideline • The Functional Independence Level I • The Spinal Cord Independence Functional status Measure is recommended as the Measure (SCIM III) is recommended as functional outcome assessment the preferred Functional Outcome tool for clinicians involved in the Assessment tool for clinicians involved assessment and care of patients in the assessment, care, and follow-up with acute spinal cord injuries. of patients with spinal cord injuries. Option • The modified Barthel index is N.A. (Not included N.A. (Not included in recommended as a functional in current current iteration) outcome assessment tool for iteration) clinicians involved in the assessment and care of patients with acute spinal cord injuries. Clinical Assessment: None Not addressed Level I • The International Spinal Cord Injury Pain Basic Pain Data Set (ISCIBPDS) is recommended as the preferred means to assess pain including pain severity, physical functioning and emotional functioning among SCI patients. (Continues)6 | VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT www.neurosurgery-online.com Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  7. 7. INTRODUCTION TABLE. Continued Previous Current Level of Level of Topic Recommendation Recommendation 2002 Recommendation Recommendation 2012 Radiographic Standard • Radiographic assessment of the Level I • In the awake, asymptomatic patient Assessment: cervical spine is not recommended who is without neck pain or Asymptomatic in trauma patients who are awake, tenderness, who has a normal Patient alert, and not intoxicated, who are neurological examination, is without without neck pain or tenderness, an injury detracting from an accurate and who do not have significant evaluation, and who is able to associated injuries that detract complete a functional range of motion from their general evaluation. examination; radiographic evaluation of the cervical spine is not recommended. • Discontinuance of cervical immobilization for these patients is recommended without cervical spinal imaging. Option • It is recommended that cervical Level III • In the awake patient with neck pain or spine immobilization in awake tenderness and normal high-quality CT patients with neck pain or imaging or normal 3-view cervical tenderness and normal cervical spine series (with supplemental CT if spine x-rays (including indicated), the following supplemental CT as necessary) be recommendations should be discontinued after wither a) normal considered: and adequate dynamic flexion/ extension radiographs, or b) a normal magnetic resonance imaging study is obtained within 48 hours of injury. 1) Continue cervical immobilization until asymptomatic, 2) Discontinue cervical immobilization following normal and adequate dynamic flexion/extension radiographs, 3) Discontinue cervical immobilization following a normal MRI obtained within 48 hours of injury (limited and conflicting Class II and Class III medical evidence), or, • Cervical spine immobilization in 4) Discontinue cervical immobilization at obtunded patients with normal the discretion of the treating physician. cervical spine x-rays (including supplemental CT as necessary) may be discontinued a after dynamic flexion/extension studies performed under fluoroscopic guidance, or b) after a normal magnetic resonance imaging study is obtained within 48 hours of injury, or c at the discretion of the treating physician. (Continues)NEUROSURGERY VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT | 7 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  8. 8. HADLEY AND WALTERS TABLE. Continued Previous Current Level of Level of Topic Recommendation Recommendation 2002 Recommendation Recommendation 2012 Radiographic Standard • A 3-view cervical spine series Level I • In the awake, symptomatic patient, Assessment: (anteroposterior, lateral, and high-quality computed tomographic Symptomatic odontoid views) is recommended (CT) imaging of the cervical spine is Patient for radiographic evaluation of the recommended. cervical spine in patients who are symptomatic after traumatic injury. This should be supplemented with computed tomography (CT) to further define areas that are suspicious or not well visualized on the plain cervical x-rays. • If high-quality CT imaging is available, routine 3-view cervical spine radiographs are not recommended. • If high-quality CT imaging is not available, a 3 view cervical spine series (AP, lateral, and odontoid views) is recommended. This should be supplemented with CT (when it becomes available) if necessary to further define areas that are suspicious or not well visualized on the plain cervical x-rays. Option • It is recommended that cervical Level III • In the awake patient with neck pain or spine immobilization in awake tenderness and normal high-quality CT patients with neck pain or imaging or normal 3-view cervical tenderness and normal cervical spine series (with supplemental CT if spine x-rays (including indicated), the following supplemental CT as necessary) be recommendations should be discontinued after either a) normal considered: and adequate dynamic flexion/ extension radiographs, or b) a normal magnetic resonance imaging study is obtained within 48 hours of injury. 1) Continue cervical immobilization until asymptomatic, 2) Discontinue cervical immobilization following normal and adequate dynamic flexion/extension radiographs, 3) Discontinue cervical immobilization following a normal MRI obtained within 48 hours of injury (limited and conflicting Class II and Class III medical evidence), or, 4) Discontinue cervical immobilization at the discretion of the treating physician. (Continues)8 | VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT www.neurosurgery-online.com Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  9. 9. INTRODUCTION TABLE. Continued Previous Current Level of Level of Topic Recommendation Recommendation 2002 Recommendation Recommendation 2012 Radiographic Option • Cervical spine immobilization in Level I • In the obtunded or un-evaluable evaluation in obtunded patients with normal patient, high-quality CT imaging is obtunded (or cervical spine x-rays (including recommended as the initial imaging unevaluable) supplemental CT as necessary) may modality of choice. If CT imaging is patients be discontinued a) after dynamic available, routine 3-view cervical spine flexion/extension studies radiographs are not recommended. performed under fluoroscopic guidance, or b) after a normal magnetic resonance imaging study is obtained within 48 hours of injury, or c) at the discretion of the treating physician. • If high-quality CT imaging is not available, a 3 view cervical spine series (AP, lateral, and odontoid views) is recommended. This should be supplemented with CT (when it becomes available) if necessary to further define areas that are suspicious or not well visualized on the plain cervical x-rays. Closed Reduction Option • Early closed reduction is Level III No changes in recommendations recommended. Cardiopulmonary Option • Management of patients with acute Level III No changes in recommendations Management SCI in a monitored setting is recommended. • Maintain mean arterial BP 85 to 90 mm Hg after SCI is recommended. Pharmacology Option • Treatment with Level I • Administration of methylprednisolone Management: methylprednisolone for either 24 (MP) for the treatment of acute SCI is Corticosteroids or 48 hours is recommended as an not recommended. Clinicians option in the treatment of patients considering MP therapy should bear in with acute spinal cord injuries that mind that the drug is not FDA should be undertaken only with approved for this application. There is the knowledge that the evidence no Class I or Class II medical evidence suggesting harmful side effects is supporting the clinical benefit of MP in more consistent than any the treatment of acute SCI. Scattered suggestion of clinical benefit. reports of Class III evidence claim inconsistent effects likely related to random chance or selection bias. However, Class I, II, and III evidence exists that high-dose steroids are associated with harmful side effects including death. Pharmacology Option • Treatment of patients with acute Level I • Administration of GM-1 ganglioside Management: GM-1 spinal cord injuries with GM-1 (Sygen) for the treatment of acute SCI Ganglioside ganglioside is recommended as an is not recommended. option without demonstrated clinical benefit. Occipital Condylar Guidelines (CT) • CT recommended to diagnose OCF. Level II (CT) No changes in recommendation Fractures: Diagnostic Option (MRI) • MRI recommended to assess Level III (MRI) ligaments. (Continues)NEUROSURGERY VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT | 9 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  10. 10. HADLEY AND WALTERS TABLE. Continued Previous Current Level of Level of Topic Recommendation Recommendation 2002 Recommendation Recommendation 2012 Occipital Condylar Option • Treatment with external cervical Level III • External cervical immobilization is Fractures: Treatment immobilization is recommended. recommended for all types of occipital condyle fractures. • More rigid external immobilization in a halo vest device should be considered for bilateral OCF. • Halo vest immobilization or occipitocervical stabilization and fusion are recommended for injuries with associated AO ligamentous injury or evidence of instability. AOD: Diagnostic None Not addressed Level I • CT imaging to determine the CCI in pediatric patients with potential AOD is recommended. Option • If there is clinical suspicion of Level III • If there is clinical or radiographic atlanto-occipital dislocation, and suspicion of AOD, and plain plain x-rays are non-diagnostic, radiographs are non-diagnostic, CT of computed tomography or the craniocervical junction is magnetic resonance imaging is recommended. The Condyle-C1 recommended, particularly for the interval (CC1) determined on CT has diagnosis of non-Type II the highest diagnostic sensitivity and dislocations. specificity for AOD among all radiodiagnostic indicators. AOD: Treatment Option • Traction may be used in the Level III • Traction is not recommended in the management of patients with management of patients with AOD, atlanto-occipital dislocation, but it and is associated with a 10% risk of is associated with a 10% risk of neurological deterioration. neurological deterioration. Atlas Fractures Option • Treatment based on specific Level III No changes in recommendations fracture type and integrity of transverse ligament. Odontoid Fracture Guideline • Treatment of Type II odontoid Level II No change in recommendations fractures based on 50 years of age. Axis Fractures: None Not addressed Level III If surgical stabilization is elected, either Odontoid anterior or posterior techniques are recommended. Axis Fractures: Option • External immobilization is Level III No changes in recommendations Hangman’s recommended. • Surgery is recommended for angulation, instability. Axis Fractures: Option • External immobilization is Level III • External immobilization for the Miscellaneous Body recommended for treatment of treatment of isolated fractures of the isolated fractures of the axis body. axis body is recommended. Consideration of surgical stabilization and fusion in unusual situations of severe ligamentous disruption and/or inability to achieve or maintain fracture alignment with external immobilization is recommended. • In the presence of comminuted fracture of the axis body, evaluation for vertebral artery injury is recommended. (Continues)10 | VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT www.neurosurgery-online.com Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  11. 11. INTRODUCTION TABLE. Continued Previous Current Level of Level of Topic Recommendation Recommendation 2002 Recommendation Recommendation 2012 Atlas/Axis Option • Treatment based on characteristics Level III No changes in recommendations Combination of axis fracture. Fractures Os Odontoideum: Option • Plain radiographs with flex/ext 6 Level III No changes in recommendations Diagnostic CT or MRI is recommended. Os Odontoideum: Option • Occipital-cervical fusion with or Level III • Occipital-cervical internal fixation and Management without C1 laminectomy may be fusion with or without C1 laminectomy considered in patients with os is recommended in patients with os odontoideum who have irreducible odontoideum who have irreducible dorsal cervicomedullary dorsal cervicomedullary compression compression and/or evidence of and/or evidence of associated associated occipital-atlantal occipital-atlantal instability. instability. Transoral decompression may be considered in patients with os odontoideum who have irreducible ventral cervicomedullary compression. • Ventral decompression should be considered in patients with os odontoideum who have irreducible ventral cervicomedullary compression. Classification of None Not addressed Level I SLIC and CSISS Subaxial Injuries Level III Harris and Allen Subaxial Cervical None Not addressed Level III • The routine use of CT and MR imaging Spinal Injuries of trauma victims with ankylosing spondylitis is recommended, even after minor trauma. • For patients with ankylosing spondylitis who require surgical stabilization, posterior long segment instrumentation and fusion, or a combined dorsal and anterior procedure is recommended. Anterior stand-alone instrumentation and fusion procedures are associated with a failure rate of up to 50% in these patients. Central Cord Option • Aggressive multimodality Level III No changes in recommendations Syndrome management of patients with ATCCS is recommended. Pediatric Injuries: None Not addressed Level I • CT imaging to determine the condyle- Diagnostic C1 interval for pediatric patients with potential AOD is recommended. Guideline • In children who have experienced Level II • Cervical spine imaging is not trauma and are alert, conversant, recommended in children who are have no neurological deficit, no greater than 3 years of age and who midline cervical tenderness, and no have experienced trauma and who: painful distracting injury, and are not intoxicated, cervical spine x- rays are not necessary to exclude cervical spine injury and are not recommended. (Continues)NEUROSURGERY VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT | 11 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  12. 12. HADLEY AND WALTERS TABLE. Continued Previous Current Level of Level of Topic Recommendation Recommendation 2002 Recommendation Recommendation 2012 • In children who have experienced trauma and who are either not alert, non-conversant, or have neurological deficit, midline cervical tenderness, or painful distracting injury, or are intoxicated, it is recommended that anteroposterior and lateral cervical spine 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 less than 3 years of age who have experienced 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 of injury. • Cervical spine radiographs or high resolution computed tomography (CT) is recommended for children who have experienced trauma and who do not meet either set of criteria above. • Three-position CT with C1-C2 motion analysis to confirm and classify the diagnosis is recommended for children suspected of having atlanto-axial rotatory fixation (AARF). Options • In children younger than age 9 Level III • AP and lateral cervical spine years who have experienced radiography or high-resolution CT is trauma, and who are non- recommended to assess the cervical conversant or haven an altered spine in children less than 9 years of mental status, a neurological age. deficit, neck pain, or painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior and lateral cervical spine x-rays be obtained. (Continues)12 | VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT www.neurosurgery-online.com Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  13. 13. INTRODUCTION TABLE. Continued Previous Current Level of Level of Topic Recommendation Recommendation 2002 Recommendation Recommendation 2012 • In children age 9 years or older who • AP, lateral, and open-mouth cervical have experienced trauma, and who spine radiography or high-resolution are non-conversant or have an CT is recommended to assess the altered mental status, cervical spine in children 9 years of age a neurological deficit, neck pain, or and older. painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior, lateral, and open-mouth cervical spine x-rays be obtained. • Computed tomographic scanning • High resolution CT scan with attention with attention to the suspected to the suspected level of neurological level of neurological injury to injury is recommended to exclude exclude occult fractures or to occult fractures or to evaluate regions evaluate regions not seen not adequately visualized on plain adequately on plain x-rays is radiographs. recommended. • Flexion/extension cervical x-rays or • Flexion and extension cervical fluoroscopy may be considered to radiographs or fluoroscopy are exclude gross ligamentous recommended to exclude gross instability when there remains ligamentous instability when there a suspicion of cervical spine remains a suspicion of cervical spinal instability after static x-rays are instability following static radiographs obtained. or CT scan. Magnetic resonance imaging of the • Magnetic resonance imaging (MRI) of cervical spine may be considered to the cervical spine is recommended to exclude cord or nerve root exclude spinal cord or nerve root compression, evaluate ligamentous compression, evaluate ligamentous integrity, or provide information integrity, or provide information regarding neurological prognosis. regarding neurological prognosis. Pediatric Injuries: None Not addressed Level III • Reduction with manipulation or halter Treatment traction is recommended for patients with acute AARF (less than 4 weeks duration) that does not reduce spontaneously. Reduction with halter or tong/halo traction is recommended for patients with chronic AARF (greater than 4 weeks duration). • Internal fixation and fusion are recommended in patients with recurrent 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 of Level III • Magnetic resonance imaging (MRI) of injury and computed tomographic the region of suspected neurological scanning with attention to the injury is recommended in a patient suspected level of neurological with SCIWORA. injury to exclude occult fractures are recommended. (Continues)NEUROSURGERY VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT | 13 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  14. 14. HADLEY AND WALTERS TABLE. Continued Previous Current Level of Level of Topic Recommendation Recommendation 2002 Recommendation Recommendation 2012 • Magnetic resonance imaging of the • Radiographic screening of the entire region of suspected neurological spinal column is recommended. injury may provide useful diagnostic information • Plain X-rays of the entire spinal • Assessment of spinal stability in column may be considered. a SCIWORA patient is recommended, using flexion-extension radiographs in the acute setting and at late follow-up, even in the presence of a MRI negative for extra-neural injury. SCIWORA: Treatment Option • External Immobilization is Level III • External immobilization of the spinal recommended until spinal stability segment of injury is recommended for is confirmed by flexion/extension up to 12 weeks. x-rays. External immobilization of the spinal • Early discontinuation of external segment of injury for up to 12 weeks immobilization is recommended for may be considered. patients who become asymptomatic and in whom spinal stability is confirmed with flexion and extension radiographs. • Avoidance of “high risk” activities • Avoidance of “high-risk” activities for for up to 6 months after spinal cord up to 6 months following SCIWORA is injury without radiographic recommended. abnormality may be considered. SCIWORA: Prognosis Option • Magnetic resonance imaging of the None Not addressed (see Diagnosis) region of neurological injury may provide useful prognostic information about neurological outcome after spinal cord injury without radiographic abnormality. Vertebral Artery Injury: Option • Conventional angiography or Level I • Computed tomographic angiography Diagnostic magnetic resonance angiography (CTA) is recommended as a screening is recommended for the diagnosis tool in selected patients after blunt of vertebral artery injury after cervical trauma who meet the nonpenetrating cervical trauma in modified Denver Screening Criteria for patients who have complete suspected vertebral artery injury (VAI). cervical spinal cord injuries, fracture through the foramen transversarium, facet dislocation, and/or vertebral subluxation. Level III • Conventional catheter angiography is recommended for the diagnosis of VAI in selected patients after blunt cervical trauma, particularly if concurrent endovascular therapy is a potential consideration, and can be undertaken in circumstances in which CTA is not available. • Magnetic resonance imaging is recommended for the diagnosis of VAI after blunt cervical trauma in patients with a complete spinal cord injury or vertebral subluxation injuries. (Continues)14 | VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT www.neurosurgery-online.com Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
  15. 15. INTRODUCTION TABLE. Continued Previous Current Level of Level of Topic Recommendation Recommendation 2002 Recommendation Recommendation 2012 Vertebral Artery Injury: Option • Anticoagulation with intravenous Level III • It is recommended that the choice of Treatment heparin is recommended for therapy for patients with VAI, patients with vertebral artery injury anticoagulation therapy vs antiplatelet who have evidence of posterior therapy vs no treatment, be circulation stroke. individualized based on the patient’s vertebral artery injury, their associated injuries and their risk of bleeding. • Either observation or treatment • The role of endovascular therapy in VAI with anticoagulation in patients has yet to be defined; therefore no with vertebral artery injuries and recommendation regarding its use in evidence of posterior circulation the treatment of VAI can be offered. ischemia is recommended. • Observation in patients with vertebral artery injuries and no evidence of posterior circulation ischemia is recommended. Venous None Not addressed Level II • Early administration of VTE prophylaxis Thromboembolism: (within 72 hours) is recommended. Prophylaxis Option • Vena cava filters are recommended Level III • Vena cava filters are not recommended for patients who do not respond to as a routine prophylactic measure, but anticoagulation or who are not are recommended for select patients candidates for anticoagulation who fail anticoagulation or who are not therapy and/or mechanical devices. candidates for anticoagulation and/or mechanical devices. Nutritional Support Option • Nutritional support of patients with Level II • Indirect calorimetry as the best means spinal cord injuries is to determine the caloric needs of recommended. Energy expenditure spinal cord injury patients is is best determined by indirect recommended. calorimetry in these patients because equation estimates of energy expenditure and subsequent caloric need tend to be inaccurate. Level III • Nutritional support of SCI patients is recommended as soon as feasible. It appears that early enteral nutrition (initiated within 72 hours) is safe, but has not been shown to affect neurological outcome, the length of stay or the incidence of complications in patients with acute SCI. The Table shows the differences in the recommendations changed, the recommendations previously made are compared tobetween the 2 sets of guidelines. One key change is that in those being made currently. Where we have introduced newnomenclature: “Standards” has been replaced by “Level I,” recommendations not included in the previous iteration of the“Guidelines” has been replaced by “Level II,” and “Options” guidelines, a statement is found indicating what the recommen-has been replaced by “Level III,” as described in detail in the dations are alongside “None” and “Not addressed,” whichMethodology section of these guidelines. Not every recommen- represents the lack of previous recommendations on a particulardation is listed since some have not changed, and the statement aspect or topic. This summary table highlighting the changes in the“No changes in recommendations” indicates that. When they have guidelines is not a substitute for reading and understanding thisNEUROSURGERY VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT | 15 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.

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