1. What is the decision or change (e.g., clinical topic, practice guideline, system design, delivery of care) you are facing or struggling with where a summary of the evidence would be helpful?

The Congress of Neurological Surgeons (CNS) published and extremely comprehensive Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries in 2013 (https://www.cns.org/guidelines/browse-guidelines-detail/introduction). CNS plans to update this guideline, in accordance with the IOM Standards for ensuring currency and accuracy of guidelines. CNS has taken all the key questions and based on the original guideline, new available literature, and pertinent clinical questions to outline a focus for this update.< Results of this systematic review will inform an evidence-based guideline update which will provide recommendations regarding the following for patients with acute cervical spinal cord injury:

• Prehospital Cervical Spinal Immobilization After Trauma and Transportation
• Clinical and Radiographic Assessment
• Fractures
• Subaxial Cervical Spine
• Other Considerations (DVTs, acute traumatic central cord syndrome, os odontoideum, pharmacologic therapy, cardiopulmonary management, etc.)
• Pediatrics

2. Why are you struggling with this issue?

According to the World Health Organization, there are between 250,000 and 500,000 people that experience spinal cord injury every year (1). Patients with acute cervical spinal cord injury are at an increased risk for mortality (2). This guideline is one of CNS’s most highlight cited and highly accessed guidelines, so we feel the update is important and will be highly impactful for clinicals and their patients.

1. Maroon, J. C., et al. (2013). "Outcomes after anterior cervical discectomy and fusion in professional athletes." Neurosurgery 73(1): 103-112.
2. Barbiellini Amidei, C., Salmaso, L., Bellio, S. et al. (2022). Epidemiology of traumatic spinal cord injury: a large population-based study. Spinal Cord 60: 812–819.
 

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

Prehospital Cervical Spinal Immobilization
• In trauma patients when should spinal immobilization be used?
• What type of transportation is recommended for patients with suspected cervical spine or spinal cord injuries?
• Where should patients with acute cervical spine or spinal cord injuries be transported?

Assessment (Clinical and Radiographic)
Neurological Examination:
• What is the preferred neurological examination tool for the assessment of acute spinal cord injury patient?
Functional Outcome Assessment:
• What is the preferred functional outcome assessment tool for clinicians involved in the assessment, care, and follow-up of patients with spinal cord injuries?
Pain Associated With Spinal Cord Injury:
• What is the preferred tool or method to assess pain, including pain severity, physical
functioning, and emotional health, when treating SCI patients?
Radiographic:
Awake, Asymptomatic Patient:
• In the awake, asymptomatic trauma patient when is radiographic assessment of the cervical spine recommended?
• In the awake, asymptomatic trauma patient, is cervical immobilization without cervical spinal imaging recommended?
Awake, Symptomatic Patient
• What symptoms and physical exam findings are characteristic of symptomatic cervical spine trauma?
• In the awake trauma patient with symptoms of cervical spine trauma/ SCI , what type of imaging is recommended?
• What immobilization is needed in the awake patient with neck pain or tenderness and normal high-quality CT imaging or normal 3-view cervical spine series?
Obtunded or Unevaluable Patient
• In the obtunded or unevaluable trauma patient what cervical spine imaging is recommended?
• In patients with normal CT, but in whom there is a high clinical suspicion of cervical spine trauma /SCI, what types of immobilization and imaging are recommended?

Fractures Closed Reduction
• In awake patients with cervical spinal fracture/dislocation injuries, when should closed reduction be used?
• In patients with cervical spinal fracture/dislocation injuries, when should MRI be used?
Occipital Condyle Fractures
• In trauma patients, what type of imaging is recommended to diagnose occipital condyle fractures (OCFs)?
• In trauma patients, what type of imaging is recommended to assess the integrity of the craniocervical ligaments?
• In patients with OCF, what type of immobilization is recommended?
Isolated Fractures in the Atlas
• In patients with an isolated fracture of the atlas with an intact transverse atlantal ligament, what treatment is recommended?
• In patients with isolated fractures of the atlas with disruption of the transverse atlantal ligament, what treatment is recommended?
Acute Combination Fractures
• What is the treatment for patients with acute combination C1-2 fractures ?

Subaxial Cervical Spine
Classifications
• What classification systems are recommended for patients with subaxial cervical spine trauma?
Treatment
• Which patients with Subaxial Cervical Spinal Injuries should be managed non-operatively?
• Should patients with Subaxial Cervical Spinal Injuries be immobilized?

Other Considerations
Acute Cardiopulmonary Management
• In patients with an acute cervical spinal cord injury, which hemodynamic goals/therapies impact neurologic recovery?
Pharmacological Therapy
• In patients with an acute cervical spinal cord injury, what pharmacologic therapies are recommended?
Atlanto-occipital Dislocation Injuries
Diagnostic
What imaging should be used in adult/pediatric patients with potential atlanto-occipital dislocation (AOD)?
Treatment
What is the indication for surgery for patients with AOD?
os odontoideum
What management is recommended for patients with os odontoideum without symptoms or neurological signs?
What management is recommended for patients with os odontoideum with symptoms or neurological signs?
What type of immobilization is recommended for patients with os odontoideum?
When is surgery recommended for patients with os odontoideum?
Nutritional Support
What type of Nutritional support is recommended for patients with spinal cord injury?
DVT
What Prophylactic treatment strategies are recommended in patients with SCI?
What is the timing of chemical prophylaxis in patients with SCI?
What diagnostic tests are recommended for identifying DVT in the spinal cord injured population?
Spinal Cord Injury without radiographic abnormality
• What imaging is recommended for patients with spinal cord injury without
radiographic abnormality?
• What treatment is recommended for patients with spinal cord injury without
radiographic abnormality?
ATCCS
• what is the best medical management for with acute traumatic central cord syndrome
(ATCCS)?
• what is the best surgical management for with acute traumatic central cord syndrome
(ATCCS)?

Pediatrics
• In pediatric patients with acute cervical spine/SCI, what is first line diagnositic imaging?
• In pediatric patients with acute cervical spine/SCI, what is the treatments should be considered?

4. When do you need the evidence report?

Wednesday, 07/17/2024

5. What will you do with the evidence report?

The purpose of this topic nomination is to evaluate all available evidence, from which, the CNS will develop a guideline to aid clinicians and guide clinical practice by determining the most appropriate evidence-based guideline recommendations for patients with acute cervical spine and spinal cord injury.

The CNS maintains in-house infrastructure to lead, promote, and support the creation and methodological processes to produce evidence-based guidelines, which are critical tools to confront a rapidly changing health care environment. Using the CNS’s high quality, rigorous methodological process, a multidisciplinary task force will develop recommendations based on the available evidence provided by the Evidence Based Practice Center. Throughout development, the task force will use evidence-based methodologies and strictly adhere to a priori defined criteria as defined by the Institute of Medicine’s (IOM) standards for conducting systematic reviews and clinical evidence-based guidelines.

This topic was initiated by the Spine and Peripheral Nerve Section of the American Academy of Neurological Surgeons (AANS)/CNS. The CNS also recruited from a variety of institutions and subspecialty disciplines in an effort to have as broad a representation of opinions and expertise as possible. It is CNS’s goal to follow the IOM recommendations to be inclusive and inter-disciplinary when constructing our guidelines and subsequent recommendations. A conscientious effort will also be made to be sure that any conflict of interest is fully disclosed and avoided. Participants who have published extensively in certain areas will be asked to recuse themselves from voting and will be assigned to evaluate evidence in other topics. Every effort will be made to ensure that the guideline is accurate, reliable, and non-biased.

The CNS guidelines attempt to provide essential information for clinicians, globally, helping to improve patient care and outcomes. In addition to developing high quality guidelines, CNS is also committed to dissemination of guidelines in multiple, open access formats, such as publication in peer-reviewed journals, publication on the CNS webpage, webinars, CNS+ app, conference seminars and courses, as well as other promotional efforts.