Global Spine Journal Special Focus issue
06 September 2017
Injury to the spinal cord can result in disturbances to normal motor and sensory function and can significantly affect a patient’s physical, psychological and social well-being. Such injuries occur along a broad continuum, from the sudden catastrophic paralysis caused by a high-speed motor vehicle accident to the slow neurologic decline from degenerative changes along the spinal axis. Both traumatic spinal cord injury (tSCI) and chronic compressive pathologies such as degenerative cervical myelopathy (DCM) represent poorly understood medical conditions as well as major health care challenges. Despite the significant impact of tSCI and DCM on quality of life and social independence, there are still substantial knowledge gaps regarding the optimal treatment of these pathologies. In order to address these knowledge gaps, AO Spine North America and International, in collaboration with the Cervical Spine Research Society and the American Association/Congress of Neurologic Surgeons, sought to develop clinical practice guidelines to outline how to best manage patients with tSCI and DCM and address existing areas of controversy.
Overview of Methods
This guideline project was an international effort that engaged neurosurgeons, orthopaedic surgeons, physiatrists, neurologists, primary care physicians and other specialists that may encounter patients with DCM or tSCI. The first step in developing these guidelines was to summarize the current body of evidence related to the management of DCM and tSCI. Systematic reviews were conducted on topics including (1) the natural history of DCM; (2) the effectiveness of nonoperative and operative management for DCM; (3) treatment options for nonmyelopathic patients with evidence of cord compression and canal stenosis; (4) the role of magnetic resonance imaging, anticoagulant prophylaxis and rehabilitation in the management of tSCI; (5) the use of methylprednisolone sodium succinate in patients with tSCI; and (6) the timing of surgical decompression for tSCI. Following a thorough examination of the literature, a multidisciplinary guideline development group used this knowledge, in combination with their clinical expertise to develop recommendations in a process that adhered to methodology proposed by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) Working Group. This methodology allows for consensus building that extends beyond merely the strength of the available scientific evidence and considers other important factors such as feasibility, acceptability and a balance of risks and benefits.
Guidelines for the management of traumatic spinal cord injury
TSCI is a devastating injury that significantly impairs a patient’s quality of life, functional status and social independence. The management of patients with tSCI has drastically evolved over the past century as a result of increasing knowledge on injury mechanisms, disease pathophysiology, and the role of surgery. There still, however, remain controversial areas surrounding certain management strategies for the treatment of tSCI, including the use of corticosteroids such as MPSS, the optimal timing of surgical intervention, the type and timing of anticoagulant prophylaxis, the role of magnetic resonance imaging in clinical decision making and prognostication, and the type and timing of rehabilitation. This lack of consensus has prevented the standardization of care across treatment centers and across the various disciplines that encounter patients with tSCI. These guidelines aim to outline how to best manage patients with tSCI, promote standardization of care and encourage clinicians to make evidence-informed decisions. This knowledge aims to improve outcomes and reduce morbidity, help patients accept a new lifestyle and facilitate their reintegration into society. The recommendations proposed by these guidelines considered the perspectives of an individual living with quadriplegia, enhancing their generalizability and applicability in a clinical setting.
Guidelines for the management of degenerative cervical myelopathy
There are several important reasons for developing guidelines for the management of patients with DCM. First, according to the World Health Organization, the proportion of the population older than 60 years is projected to double from 11% in 2010 to 22% in 2050. This unprecedented upward shift in the age structure of the global population will pose unique challenges to health care systems worldwide as elderly patients tend to have multiple medical comorbidities, decreased mobility, poor balance, a greater propensity to falls and more severe spinal degeneration. Furthermore, these individuals experience age-related changes in the composition of their spinal cord, have reduced physiological reserves, and may be less tolerant to certain interventions. By summarizing current evidence, these guidelines will help evaluate the safety and efficacy of various treatment modalities and provide guidance on the management of elderly myelopathic patients. Second, there is also an increased reported prevalence of myelopathy in individuals aged 50 to 60 years, likely due to improved diagnostic techniques. Patients with myelopathy experience greater functional impairment, a decrease in social independence, and substantially reduced quality of life. Long-term disability in patients aged 50 to 60 years also poses greater financial burden on society as individuals in their mid-50s are at the peak of their working career.
These guidelines will therefore not only ensure appropriate management in the elderly population but will also define treatment strategies for patients whose professional duties and other activities of daily living might be significantly impaired.
The main areas of focus of these guidelines include defining the natural history of DCM; outlining the management of mild, moderate, and severe myelopathic patients; quantifying the expected outcomes of surgical and non-surgical treatment for these populations; and discussing the management of nonmyelopathic patients with image evidence of cord compression or canal stenosis.
Michael Fehlings, chairperson of the AO Spine Knowledge Forum and the leader of both guideline projects, speaks of the impact these guidelines will have in clinical practices.
“Both traumatic and nontrauamtic spinal cord injury result in devastating functional impairments and reduced quality of life. The last 10 years have witnessed significant improvements in the management of these conditions due to improved knowledge surrounding injury mechanisms, disease pathophysiology and the impact of surgery. These guidelines distill, for the first time, existing evidence on these topics and aim to develop recommendations to outline how to manage patients with degenerative cervical myelopathy and traumatic spinal cord injury. We hope these guidelines will promote shared decision making among physicians, patients and their families, standardize care worldwide and encourage future research to address existing knowledge gaps.”
Lindsay Tetreault (PhD), a postdoctoral fellow from the Toronto Western Hospital and a medical student at the University College Cork, discussed the merits of developing clinical practice guidelines for SCI and DCM
“There was a pressing need to develop clinical practice guidelines to outline how to best manage patients with varying severities of myelopathy and to resolve existing areas of controversy in the treatment of traumatic spinal cord injury. These guidelines represent the judgement of a team of experienced clinicians and methodologists, and also consider the perspectives of patient advocates. We hope that our recommendations will encourage evidence-based medicine, reduce health care variations and improve overall quality of care.
These guidelines would not be possible without the generous support of AO Spine North America, AO Spine International, the Cervical Spine Research Society, the American Association of Neurological Sugeons, the Congress of Neurological Surgeons and the AO Spine Knowledge Forum for Spinal Cord Injury.