About a decade ago, the Joint Section on Disorders of the Spine and Peripheral Nerves of the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) released guidelines for the management of acute cervical spine and spinal cord injuries. Since that time, progress has been made in several clinical research areas. In 2013, the CNS and AANS updated the practice guidelines, identifying best practices and providing support for patient access to safe and effective treatments.
The updated guidelines are intended to serve as a useful guide to help clinicians make important decisions in the care of these patients. The guidelines are published in Neurosurgery.
Comprehensive Recommendations for Spinal Cord Injuries
The updated guidelines offer 22 chapters on various aspects of care for patients with cervical spine and spinal cord injuries. There are 112 evidence-based recommendations offered in the document, compared with only 76 recommendations when the first guidelines were released in 2002. Within these chapters are 19 level I recommendations, each of which are supported by Class I medical evidence:
Aspect of Care
Number of Level I Recommendations
Assessment of functional outcomes
Assessment of pain after spinal cord injuries
Diagnosis of atlanto-occipital dislocation injuries
Cervical subaxial injury classification schemes
Pediatric spinal injuries
Vertebral artery injuries
An additional 16 level II and 77 level III recommendations are provided, based on Class II and Class III medical evidence, respectively.
Examining Steroid Use in Acute Spinal Cord Injury
One of the key new changes from the previously issued guidelines is that, for the first time, the use of steroids is not recommended in acute spinal cord injury in the first 24 to 48 hours after an injury is sustained. The revision was made based on a lack of medical evidence supporting the benefits of using these drugs in the clinical setting. In fact, a compelling case is made from high-quality clinical studies that demonstrate a greater propensity for these medications to harm rather than benefit patients with spinal cord injuries.
More Work Needed to Manage Traumatic Injuries
Despite this guideline update, more comparative clinical studies are needed to further our understanding on the best ways to assess, diagnose, image, and treat patients with these acute traumatic injuries. We also have many topics within this field of care for which there is simply not enough meaningful or convincing medical evidence in our literature. In the meantime, the hope is that these guidelines can help clinicians with assessing, managing, and treating patients using the best evidence available to reduce the growing societal and healthcare burden of these injuries.
Resnick DK. Updated guidelines for the management of acute cervical spine and spinal cord injury. Neurosurgery. 2013;72(Suppl ):1. Available at: http://journals.lww.com/neurosurgery/toc/2013/03002.
Aebli N, Rüegg TB, Wicki AG, Petrou N, Krebs J. Predicting the risk and severity of acute spinal cord injury after a minor trauma to the cervical spine. Spine J. 2013 Mar 21 [Epub ahead of print].
Ahn H, Singh J, Nathens A, et al. Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and evidence-based guidelines. J Neurotrauma. 2011;28:1341-1361.
Pimentel L, Diegelmann L. Evaluation and management of acute cervical spine trauma. Emerg Med Clin North Am. 2010;28:719-738.