A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis

A Clinical Practice Guideline on the Timing of Surgical Decompression and Hemodynamic Management of Acute Spinal Cord Injury and the Prevention, Diagnosis, and Management of Intraoperative Spinal Cord Injury: Introduction, Rationale, and Scope

STUDY DESIGN

Protocol for the development of clinical practice guidelines following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards.

OBJECTIVES

Acute SCI or intraoperative SCI (ISCI) can have devastating physical and psychological consequences for patients and their families. The treatment of SCI has dramatically evolved over the last century as a result of preclinical and clinical research that has addressed important knowledge gaps, including injury mechanisms, disease pathophysiology, medical management, and the role of surgery. In an acute setting, clinicians are faced with critical decisions on how to optimize neurological recovery in patients with SCI that include the role and timing of surgical decompression and the best strategies for hemodynamic management. The lack of consensus surrounding these treatments has prevented standardization of care across centers and has created uncertainty with respect to how to best manage patients with SCI. ISCI is a feared complication that can occur in the best of hands. Unfortunately, there are no systematic reviews or clinical practice guidelines to assist spine surgeons in the assessment and management of ISCI in adult patients undergoing spinal surgery. Given these limitations, it is the objective of this initiative to develop evidence-based recommendations that will inform the management of both SCI and ISCI. This protocol describes the rationale for developing clinical practice guidelines on (i) the timing of surgical decompression in acute SCI; (ii) the hemodynamic management of acute SCI; and (iii) the prevention, identification, and management of ISCI in patients undergoing surgery for spine-related pathology.

METHODS

Systematic reviews were conducted according to PRISMA standards in order to summarize the current body of evidence and inform the guideline development process. The guideline development process followed the approach proposed by the GRADE working group. Separate multidisciplinary, international groups were created to perform the systematic reviews and formulate the guidelines. All potential conflicts of interest were vetted in advance. The sponsors exerted no influence over the editorial process or the development of the guidelines.

RESULTS

This process resulted in both systematic reviews and clinical practice guidelines/care pathways related to the role and timing of surgery in acute SCI; the optimal hemodynamic management of acute SCI; and the prevention, diagnosis and management of ISCI.

CONCLUSIONS

The ultimate goal of this clinical practice guideline initiative was to develop evidence-based recommendations for important areas of controversy in SCI and ISCI in hopes of improving neurological outcomes, reducing morbidity, and standardizing care across settings. Throughout this process, critical knowledge gaps and future directions were also defined.

Longitudinal multiparametric MRI of traumatic spinal cord injury in animal models

Multi-parametric MRI (mpMRI) technology enables non-invasive and quantitative assessments of the structural, molecular, and functional characteristics of various neurological diseases. Despite the recognized importance of studying spinal cord pathology, mpMRI applications in spinal cord research have been somewhat limited, partly due to technical challenges associated with spine imaging. However, advances in imaging techniques and improved image quality now allow longitudinal investigations of a comprehensive range of spinal cord pathological features by exploiting different endogenous MRI contrasts. This review summarizes the use of mpMRI techniques including blood oxygenation level-dependent (BOLD) functional MRI (fMRI), diffusion tensor imaging (DTI), quantitative magnetization transfer (qMT), and chemical exchange saturation transfer (CEST) MRI in monitoring different aspects of spinal cord pathology. These aspects include cyst formation and axonal disruption, demyelination and remyelination, changes in the excitability of spinal grey matter and the integrity of intrinsic functional circuits, and non-specific molecular changes associated with secondary injury and neuroinflammation. These approaches are illustrated with reference to a nonhuman primate (NHP) model of traumatic cervical spinal cord injuries (SCI). We highlight the benefits of using NHP SCI models to guide future studies of human spinal cord pathology, and demonstrate how mpMRI can capture distinctive features of spinal cord pathology that were previously inaccessible. Furthermore, the development of mechanism-based MRI biomarkers from mpMRI studies can provide clinically useful imaging indices for understanding the mechanisms by which injured spinal cords progress and repair. These biomarkers can assist in the diagnosis, prognosis, and evaluation of therapies for SCI patients, potentially leading to improved outcomes.

Updates in the Early Management of Acute Spinal Cord Injury

Spinal cord injury (SCI) is a leading cause of disability worldwide, and effective management is necessary to improve clinical outcomes. Many long-standing therapies including early reduction and spinal cord decompression, methylprednisolone administration, and optimization of spinal cord perfusion have been around for decades; however, their efficacy has remained controversial because of limited high-quality data. This review article highlights studies surrounding the role of early surgical decompression and its role in relieving mechanical pressure on the microvascular circulation thereby reducing intraspinal pressure. Furthermore, the article touches on the current role of methylprednisolone and identifies promising studies evaluating neuroprotective and neuroregenerative agents. Finally, this article outlines the expanding body of literature evaluating mean arterial pressure goals, cerebrospinal fluid drainage, and expansive duroplasty to further optimize vascularization to the spinal cord. Overall, this review aims to highlight evidence for SCI treatments and ongoing trials that may markedly affect SCI care in the near future.

Intramuscular Hematomas in Patients Receiving Prophylaxis or Anticoagulant Treatment after Spinal Cord Injury (SCI)-A Rare Complication: Description of Seven Cases and a Literature Analysis

Spinal cord injuries (SCIs) are associated with a high risk of thromboembolic complications (VTE), despite the use of antithrombotic prophylaxis in the form of low-molecular-weight heparin (LMWH). The occurrence of VTE requires, as in other diseases, full-dose antithrombotic treatment. Herein, we describe seven cases of soft tissue hemorrhagic complications in the form of spontaneous intramuscular hematomas (SMHs) in patients after SCI undergoing rehabilitation. Four patients received anticoagulant therapy due to previously diagnosed deep vein thrombosis (DVT), and three patients received anticoagulant prophylaxis. None of the patients had a significant injury immediately before the hematoma appeared, and the only symptom was a sudden swelling of the limb without accompanying pain. The hematomas in all patients were treated conservatively. In three patients, significant decreases in hemoglobin were observed; in one patient, a blood transfusion was required for this reason. In all patients treated via anticoagulation, the anticoagulation treatment was modified at the time of diagnosis of the hematoma; in three patients, oral anticoagulants were changed to LMWH in a therapeutic dose, while in one patient, anticoagulant treatment was completely discontinued. Conclusions: Intramuscular hematomas are rare complications after SCI. Each sudden swelling of a limb requires ultrasound-based diagnostics. At the time of diagnosis of a hematoma, the level of hemoglobin and the size of the hematoma should be monitored. The treatment or anticoagulation prophylaxis should be modified if necessary.

Timing of venous thromboembolism chemoprophylaxis using objective hemoglobin criteria in blunt solid organ injury

BACKGROUND

The purpose of this study was to evaluate the safety and efficacy of early venous thromboembolism (VTE) chemoprophylaxis following blunt solid organ injury.

METHODS

A retrospective review of patients was performed for patients with blunt solid organ injury between 2009-2019. Enoxaparin was initiated when patients had <1g/dl Hemoglobin decline over a 24 h period. These patients were then categorized by initiation: ≤48 h and >48 h.

RESULTS

There were 653 patients: 328 (50.2%) <48 h and 325 (49.8%) ≥48 h. Twenty-nine (4.4%) developed VTE. Patients in ≥48 h group suffered more frequent VTE events (6.5% vs 2.4%, p = 0.021). Non-operative failure occurred in 6 patients (1.9%) in ≥48 h group, and 5 patients (1.5%) < 48 h group. Blood transfusion following chemophrophylaxis initiation was required in 69 (21.3%) in ≥48 h group, and 46 (14.0%) in < 48 h group, occurring similarly between groups (p=0.021).

CONCLUSION

Stable hemoglobin in the first 24 h is an efficacious, objective measure that allows early initiation of VTE chemoprophylaxis in solid organ injury. This practice is associated with earlier initiation of and fewer VTE events.

A critical appraisal of clinical practice guidelines for management of four common complications after spinal cord injury

BACKGROUND CONTEXT

Complications such as pressure sores, pulmonary infection, urinary tract infection (UTI), and venous thromboembolism (VTE) are common after spinal cord injury (SCI). These have serious consequences for patients' physical, social, and vocational well-being. Several authoritative organizations have developed guidelines for managing these complications after SCI.

PURPOSE

We aim to systematically review and appraise guidelines on the management of four common complications (pressure sores, pulmonary infection, UTI, and VTE) after SCI as well as to summarize relevant recommendations and assess the quality of their supporting evidence.

DESIGN

Systematic review.

METHODS

We searched Medline, Embase, Cochrane, and Web of Science, as well as guideline-specific databases (e.g., National Guideline Clearinghouse) and Google Scholar, from January 2000 to January 2022. We included the most updated guidelines developed by specific authoritative organizations. We evaluated the included guidelines using the Appraisal of Guidelines for Research and Evaluation 2nd edition instrument, which measures six domains (e.g., applicability). Recommendations extracted from guidelines were categorized as for, against, or neither for nor against. An evidence assessment was adopted to classify the quality of supporting evidence as poor, fair, or good.

RESULTS

Eleven guidelines from 2005 to 2020 were included, all of which, among the six domains, scored lowest in the domain of applicability. For pressure sores, guidelines recommended for skin inspection, repositioning, and the use of pressure reduction equipment as preventive measures and dressings, debridement, and surgery as treatment measures. For pulmonary infection, guidelines recommended for physical (e.g., the use of an insufflation-exsufflation device) and pharmacological measures (e.g., the use of bronchodilators). For UTI, guidelines recommended for antibiotics as a treatment measure but recommended against cranberries, methenamine salts, and acidification or alkalinization agents as preventive measures. For VTE prophylaxis, five guidelines recommended for low molecular weight heparin (LMWH). Three guidelines recommended against unfractionated heparin, whereas one guideline recommended for it. Most of the supporting evidence was of poor quality (130/139), and the rest was of fair quality (9/139).

CONCLUSIONS

For pressure sores, pulmonary infection, and UTI, evidence of poor to fair quality indicated consistent recommendations for prevention and treatment measures. For VTE, LMWH was consistently recommended, whereas recommendations on the use of unfractionated heparin were controversial.

Significance of spinal cord perfusion pressure following spinal cord injury: A systematic scoping review

This scoping review systematically reviewed relevant research to summarize the literature addressing the significance of monitoring spinal cord perfusion pressure (SCPP) in acute traumatic spinal cord injury (SCI). The objectives of the review were to (1) examine the nature of research in the field of SCPP monitoring in SCI, (2) summarize the key research findings in the field, and (3) identify research gaps in the existing literature and future research priorities. Primary literature searches were conducted using databases (Medline and Embase) and expanded searches were conducted by reviewing the references of eligible articles and searches of Scopus, Web of Science core collection, Google Scholar, and conference abstracts. Relevant data were extracted from the studies and synthesis of findings was guided by the identification of patterns across studies to identify key themes and research gaps within the literature. Following primary and expanded searches, a total of 883 articles were screened. Seventy-three articles met the review inclusion criteria, including 34 original research articles. Other articles were categorized as conference abstracts, literature reviews, systematic reviews, letters to the editor, perspective articles, and editorials. Key themes relevant to the research question that emerged from the review included the relationship between SCPP and neurological recovery, the safety of monitoring pressures within the intrathecal space, and methods of intervention to enhance SCPP in the setting of acute traumatic SCI. Original research that aims to enhance SCPP by targeting increases in mean arterial pressure or reducing pressure in the intrathecal space is reviewed. Further discussion regarding where pressure within the intrathecal space should be measured is provided. Finally, we highlight research gaps in the literature such as determining the feasibility of invasive monitoring at smaller centers, the need for a better understanding of cerebrospinal fluid physiology following SCI, and novel pharmacological interventions to enhance SCPP in the setting of acute traumatic SCI. Ultimately, despite a growing body of literature on the significance of SCPP monitoring following SCI, there are still a number of important knowledge gaps that will require further investigation.

Advancements in the treatment of traumatic spinal cord injury during military conflicts

Significant advancements in the treatment of spinal cord injury (SCI) were developed in the setting of military conflicts, partly due to the large numbers of injuries sustained by service members. No effective SCI treatment options existed into the early 20th century, and soldiers who sustained these injuries were usually considered untreatable. Extensive progress was made in SCI treatment during and after World War II, as physical therapy was increasingly encouraged for patients with SCI, multidisciplinary teams oversaw care, pathophysiology was better understood, and strategies were devised to prevent wound infection and pressure sores. Recent conflicts in Iraq and Afghanistan have caused a substantial rise in the proportion of SCIs among causes of casualties and wounds, largely due to new forms of war and weapons, such as improvised explosive devices. Modern military SCIs resulting from blast mechanisms are substantively different from traumatic SCIs sustained by civilians. The treatment paradigms developed over the past 100 years have increased survival rates and outcomes of soldiers with SCI. In this paper, the authors review the role of military conflicts in the development of therapeutic interventions for SCI and discuss how these interventions have improved outcomes for soldiers and civilians alike.

Adopting Clinical Practice Guidelines for Pharmacologic Management of Acute Spinal Cord Injury from a Developed World Context to a Developing Global Region

BACKGROUND

Proper utilization of high-quality clinical practice guidelines (CPGs) eliminates the dependence of patients' outcomes on the ability and knowledge of "individual" health care providers and reduces unwarranted variation in care. The aim of this study was to adapt/adopt two CPGs for pharmacologic management of acute spinal cord injury (SCI) using guideline adaptation methods.

METHODS

This study was conducted based on the ADAPTE process. Following establishment of an organizing committee and choosing the health topics, we appraised the quality of the CPGs using the Appraisal of Clinical Guidelines for Research & Evaluation II (AGREE II). Then, the authors extracted and categorized suggestions according to Population, Intervention, Professions, Outcomes and Health care setting (PIPOH). The decision-making process was based on systemic evaluation of each suggestion, utilizing a combination of AGREE II scores, the quality of supporting evidence for or against each suggestion and the triad of feasibility, acceptance and adoptability for the Iranian health-care context.

RESULTS

Two guidelines were included in the adaptation process. Based on high-quality of these guidelines and the feasibility and adoptability evaluation of the organizing committee, we decided to adopt the suggestion of both guidelines. Overall, seven suggestions were extracted from the source guidelines.

CONCLUSION

This work provides a framework to apply guidelines for acute SCI to the developing regions of the world. Attempts should be made to implement these suggestions in order to improve the health outcomes of Iranian SCI patients.

Factors Affecting the Decision to Initiate Anticoagulation After Spine Surgery: Findings From the AOSpine Anticoagulation Global Initiative

STUDY DESIGN

Cross-sectional, international survey.

OBJECTIVES

To identify factors influencing pharmacologic anticoagulation initiation after spine surgery based on the AOSpine Anticoagulation Global Survey.

METHODS

This survey was distributed to the international membership of AOSpine (n = 3805). A Likert-type scale described grade practice-specific factors on a scale from low (1) to high (5) importance, and patient-specific factors a scale from low (0) to high (3) importance. Analysis was performed to determine which factors were significant in the decision making surrounding the initiation of pharmacologic anticoagulation.

RESULTS

A total of 316 spine surgeons from 64 countries completed the survey. In terms of practice-specific factors considered to initiate treatment, expert opinion was graded the highest (mean grade ± SD = 3.2 ± 1.3), followed by fellowship training (3.2 ± 1.3). Conversely, previous studies (2.7 ± 1.2) and unspecified guidelines were considered least important (2.6 ± 1.6). Patient body mass index (2.0 ± 1.0) and postoperative mobilization (2.3 ± 1.0) were deemed most important and graded highly overall. Those who rated estimated blood loss with greater importance in anticoagulation initiation decision making were more likely to administer thromboprophylaxis at later times (hazard ratio [HR] = 0.68-0.71), while those who rated drain output with greater importance were likely to administer thromboprophylaxis at earlier times (HR = 1.32-1.43).

CONCLUSION

Among our global cohort of spine surgeons, certain patient factors (ie, patient mobilization and body mass index) and practice-specific factors (ie, expert opinion and fellowship training) were considered to be most important when considering anticoagulation start times.

The impact of surgical timing on motor level lowering in motor complete traumatic spinal cord injury patients

Patients with motor complete traumatic spinal cord injury (tSCI) have a low potential to recover ambulation. Motor level recovery, adjacent to the level of injury, could influence functional independency. This study addresses whether surgical timing influences motor level recovery in patients with sensorimotor complete (AIS A) and motor complete sensory incomplete (AIS B) tSCI. A retrospective cohort study was performed in the Netherlands in patients with motor complete tSCI (C2-L2), who consecutively underwent surgery between January 2010 and April 2020. Neurological examination was performed directly at presentation to the ER and at discharge from the rehabilitation facility. Motor level lowering, AIS grade and Upper and Lower Extremity Motor Score (UEMS and LEMS) recovery were calculated for patients who underwent early (<24h) and late (24h+) surgery. A total of 96 patients met the inclusion criteria. In the multivariate analysis late surgical decompression (24h+) was negatively associated with ≥1 motor level lowering and ≥2 AIS grade improvement (Odds Ratio (OR) 0.11 (95% CI: 0.01, 0.67) p=0.046, OR 0.06 (95% CI: 0.00, 047) p=0.030). The presence of sacral sparing (AIS B) at initial examination, and cervical level of the tSCI were associated with ≥1 motor level lowering. In addition, AOSpine C-type injuries were negatively associated with any type of neurological recovery, except motor level lowering. Although sensorimotor complete injuries as well as thoracolumbar injuries negatively influence neurological recovery, early surgical decompression (<24h) appears independently associated with enhanced neurological recovery in patients with traumatic spinal cord injury despite level and severity of injury.

Natural History of Isolated Below-Knee Vein Thrombosis in Patients with Spinal Cord Injury

In the general population, serial imaging is recommended over anticoagulant therapy for below-knee deep vein thrombosis (BKDVT). However, no clinical trial in Asian patients with spinal cord injury and BKDVT has been performed. Therefore, we evaluated the natural course of BKDVT in patients with acute spinal cord injury. We retrospectively analyzed inpatients with spinal cord injury with BKDVT between 2016 and 2020. All patients underwent inpatient rehabilitation treatment and duplex ultrasonographic examination of both the lower extremities at follow-up. After screening 172 patients with acute spinal cord injury for deep vein thrombosis using duplex ultrasound, 27 patients with below-the-knee deep vein thrombosis were included in this study. The mean lower-extremity motor score (median, interquartile range) was 66.0, 54.0–74.5. Sixteen patients received a non-vitamin K antagonist oral anticoagulant (NOAC) for anticoagulation. None of the patients had proximal propagation according to the follow-up duplex ultrasonography. BKDVT disappearance was not significantly different between the NOAC treatment and non-treatment groups. Asian patients with spinal cord injury have a low incidence of venous thromboembolism and favorable natural history of BKDVT. We recommend serial imaging over anticoagulant therapy for BKDVT in these patients.

Evaluation of the quality of published SCI clinical practice guidelines using the AGREE II instrument: Results from Can-SCIP expert panel

INTRODUCTION

Spinal cord injury (SCI) is a complex condition with substantial adverse personal, social and economic impacts necessitating evidence-based inter-professional care. To date, limited studies have assessed the quality of clinical practice guidelines (CPGs) within SCI. The aim of this study is to evaluate the quality of the development process and methodological rigour of published SCI CPGs across the care continuum from pre-hospital to community-based care.

METHODS

Electronic health databases and indexes were searched to identify English or French language CPGs within SCI published within the last nine years with specific evidence-based recommendations applicable to the Canadian health care setting. Eligible CPGs were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

RESULTS

A total of forty-one CPGs that met the inclusion criteria were appraised by at least four raters. There was high variability in quality. Twenty-seven CPGs achieved a good rigour of development domain score of >70%. Other standardized mean domain scores were scope and purpose (85.32%), stakeholder involvement (65.03%), clarity of presentation (84.81%), applicability (55.55%) and editorial independence (75.83%). The agreement between appraisers (intraclass correlation coefficient) was high (intraclass correlation coefficient > 0.80).

CONCLUSION

There is a paucity of CPGs that address community-based specialized rehabilitation and community reintegration. Furthermore, many CPGs only focus on a single impairment at one time point in the care continuum. As SCI is a complex condition that results in multimorbidity and requires health monitoring and intervention across the lifespan, a rigorously developed CPG that addresses high-quality, interprofessional comprehensive care is needed.

Development of the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline: Methods and overview

INTRODUCTION

Spinal cord injury (SCI) is a life-altering injury that leads to a complex constellation of changes in an individual's sensory, motor, and autonomic function which is largely determined by the level and severity of cord impairment. Available SCI-specific clinical practice guidelines (CPG) address specific impairments, health conditions or a segment of the care continuum, however, fail to address all the important clinical questions arising throughout an individual's care journey. To address this gap, an interprofessional panel of experts in SCI convened to develop the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline. This article provides an overview of the methods underpinning the Can-SCIP Guideline process.

METHODS

The Can-SCIP Guideline was developed using the Guidelines Adaptation Cycle. A comprehensive search for existing SCI-specific CPGs was conducted. The quality of eligible CPGs was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. An expert panel (n = 52) convened, and groups of relevant experts met to review and recommend adoption or refinement of existing recommendations or develop new recommendations based on evidence from systematic reviews conducted by the Spinal Cord Injury Research Evidence (SCIRE) team. The expert panel voted to approve selected recommendations using an online survey tool.

RESULTS

The Can-SCIP Guideline includes 585 total recommendations from 41 guidelines, 96 recommendations that pertain to the Components of the Ideal SCI Care System section, and 489 recommendations that pertain to the Management of Secondary Health Conditions section. Most recommendations (n = 281, 48%) were adopted from existing guidelines without revision, 215 (36.8%) recommendations were revised for application in a Canadian context, and 89 recommendations (15.2%) were created de novo.

CONCLUSION

The Can-SCIP Guideline is the first living comprehensive guideline for adults with SCI in Canada across the care continuum.

Perioperative Anticoagulation Management in Spine Surgery: Initial Findings From the AO Spine Anticoagulation Global Survey

STUDY DESIGN

Cross-sectional, international survey.

OBJECTIVES

This study addressed the global perspectives concerning perioperative use of pharmacologic thromboprophylaxis during spine surgery along with its risks and benefits.

METHODS

A questionnaire was designed and implemented by expert members in the AO Spine community. The survey was distributed to AO Spine's spine surgeon members (N = 3805). Data included surgeon demographic information, type and region of practice, anticoagulation principles, different patient scenarios, and comorbidities.

RESULTS

A total of 316 (8.3% response rate) spine surgeons completed the survey, representing 64 different countries. Completed surveys were primarily from Europe (31.7%), South/Latin America (19.9%), and Asia (18.4%). Surgeons tended to be 35 to 44 years old (42.1%), fellowship-trained (74.7%), and orthopedic surgeons (65.5%) from academic institutions (39.6%). Most surgeons (70.3%) used routine anticoagulation risk stratification, irrespective of geographic location. However, significant differences were seen between continents with anticoagulation initiation and cessation methodology. Specifically, the length of a procedure (P = .036) and patient body mass index (P = .008) were perceived differently when deciding to begin anticoagulation, while the importance of medical clearance (P < .001) and reference to literature (P = .035) differed during cessation. For specific techniques, most providers noted use of mobilization, low-molecular-weight heparin, and mechanical prophylaxis beginning on postoperative 0 to 1 days. Conversely, bridging regimens were bimodal in distribution, with providers electing anticoagulant initiation on postoperative 0 to 1 days or days 5-6.

CONCLUSION

This survey highlights the heterogeneity of spine care and accentuates geographical variations. Furthermore, it identifies the difficulty in providing consistent perioperative anticoagulation recommendations to patients, as there remains no widely accepted, definitive literature of evidence or guidelines.

Guideline for diagnosis and treatment of spine trauma in the epidemic of COVID-19

Outbreak of COVID-19 is ongoing all over the world. Spine trauma is one of the most common types of trauma and will probably be encountered during the fight against COVID-19 and resumption of work and production. Patients with unstable spine fractures or continuous deterioration of neurological function require emergency surgery. The COVID-19 epidemic has brought tremendous challenges to the diagnosis and treatment of such patients. To coordinate the diagnosis and treatment of infectious disease prevention and spine trauma so as to formulate a rigorous diagnosis and treatment plan and to reduce the disability and mortality of the disease, multidisciplinary collaboration is needed. This expert consensus is formulated in order to (1) prevent and control the epidemic, (2) diagnose and treat patients with spine trauma reasonably, and (3) reduce the risk of cross-infection between patients and medical personnel during the treatment.

Venous Thromboembolism Chemoprophylaxis Within 24 Hours of Surgery for Spinal Cord Injury: Is It Safe and Effective?

OBJECTIVE

Current guidelines recommend initiation of venous thromboembolism (VTE) chemoprophylaxis within 72 hours of spinal cord injury (SCI). This study investigated the safety and efficacy of chemoprophylaxis within 24 hours of surgery for SCI.

METHODS

A retrospective review of 97 consecutive patients who underwent surgery for acute traumatic SCI at a single level 1 trauma center from 2013-2018 was performed. VTE/postoperative bleeding rates during hospitalization, demographics, medical/surgical complications, drain output, length of stay, and disposition were obtained. Chi-square with odds ratios (ORs), 1-way analysis of variance, and logistic regression were performed to establish significant differences between groups.

RESULTS

Seventy-nine patients were included, 49 received chemoprophylaxis within 24 hours and 20 within 24-72 hours. Cohort characteristics included an average age of 51.8 years, 77.2% male, 62.0% cervical, and 35.4% thoracic SCIs. Using the American Spinal Injury Association Impairment Scale (AIS), 39.2% were AIS-A injuries, 19.0% AIS-B, 25.3% AIS-C, and 16.5% AIS-D. Unfractionated heparin was administered in 88.6% of patients and 11.4% received low molecular weight heparin. Chemoprophylaxis within 24 hours of surgery was associated with a lower rate of VTE (6.1% vs. 35.0%; OR, 0.121; 95% confidence interval [CI], 0.027-0.535) and deep vein thrombosis (4.1% vs. 30.0%; OR, 0.099; 95% CI, 0.018-0.548) versus 24-72 hours. Pulmonary embolism rates were not significantly different (6.1% vs. 5.0%, p = 1.0). There were no postoperative bleeding complications and no significant difference in drain output between cohorts.

CONCLUSION

Early VTE chemoprophylaxis is effective with lower VTE rates when initiated within 24 hours of surgery for SCI and is safe with no observed postoperative bleeding complications.

Quality and Safety Improvement in Spine Surgery

STUDY DESIGN

Review article.

OBJECTIVES

A narrative review of the literature on the current advances and limitations in quality and safety improvement initiatives in spine surgery.

METHODS

A comprehensive literature search was performed using Ovid MEDLINE focusing on 3 preidentified concepts: (1) quality and safety improvement, (2) reporting of outcomes and adverse events, and (3) prediction model and practice guidelines. The search was conducted under appropriate subject headings and using relevant text words. Articles were screened, and manuscripts relevant to this discussion were included in the narrative review.

RESULTS

Quality and safety improvement remains a major research focus attracting investigators from the global spine community. Multiple databases and registries have been developed for the purpose of generating data and monitoring the progress of quality and safety improvement initiatives. The development of various prediction models and clinical practice guidelines has helped shape the care of spine patients in the modern era. With the reported success of exemplary programs initiated by the Northwestern and Seattle Spine Team, other quality and safety improvement initiatives are anticipated to follow. However, despite these advancements, the reporting metrics for outcomes and adverse events remain heterogeneous in the literature.

CONCLUSION

Constant surveillance and continuous improvement of the quality and safety of spine treatments is imperative in modern health care. Although great advancement has been made, issues with reporting outcomes and adverse events persist, and improvement in this regard is certainly needed.

Advances in the Rehabilitation of the Spinal Cord-Injured Patient: The Orthopaedic Surgeons' Perspective

Acute traumatic spinal cord injury is a devastating condition affecting 17,700 new patients per year in the United States alone. Typically, orthopaedic surgeons focus on managing the acute surgical aspects of care (eg, surgical spinal decompression and stabilization). However, in the care of these patients, being familiar with how to prognosticate neurologic recovery and manage secondary complications is extremely important. In addition, as an integral part of the multidisciplinary care team, the surgeon should have an awareness of contemporary rehabilitation approaches to maximize function and facilitate reintegration into the community. The purpose of this review article is to provide a surgeon's perspective on these aspects of spinal cord injury care.

Development and Implementation of Clinical Practice Guidelines: An Update and Synthesis of the Literature With a Focus in Application to Spinal Conditions

STUDY DESIGN

Review.

OBJECTIVES

The objectives of this review are to (a) summarize the role of clinical practice guidelines (CPGs), (b) outline the methodology involved in formulating CPGs, (c) provide an illustration of these principles using a CPG developed for degenerative cervical myelopathy, and (d) highlight the importance of knowledge translation.

METHODS

A review of the literature was conducted to summarize current standards in CPG development and implementation.

RESULTS

CPGs are systematically developed statements intended to affect decisions made by health care providers, policy makers, and patients. The main objectives of CPGs are to synthesize and translate evidence into recommendations, optimize patient outcomes, standardize care, and facilitate shared decision making among physicians, patients, and their caregivers. The main steps involved in the development of CPGs include defining the clinical problem, assembling a multidisciplinary guideline development group and systematic review team, conducting a systematic review of the literature, translating the evidence to recommendations, critically appraising the CPG and updating the document when new studies arise. The final step in developing a CPG is to implement it into clinical practice; this step requires an assessment of the barriers to implementation and the formulation of effective dissemination strategies.

CONCLUSION

CPGs are an important component in the teaching and practice of medicine and are available for a wide spectrum of diseases. CPGs, however, can only be used to influence clinical practice if the recommendations are informed by a systematic review of the literature and developed using rigorous methodology. The opportunity to transform clinical management of spinal conditions is an attractive outcome of the application of high-quality CPGs.

Duplex ultrasound surveillance for deep vein thrombosis after acute traumatic spinal cord injury at rehabilitation admission

Context/objective: To determine the prevalence of deep vein thrombosis (DVT) detected through routine duplex screening and factors associated with DVT in spinal cord injury (SCI) patients on admission to rehabilitation.Design: Retrospective chart review of medical records.Setting: Acute inpatient rehabilitation.Participants: One hundred and eighty-nine individuals admitted to rehabilitation within 2 weeks of initial traumatic SCI who underwent routine surveillance with duplex scan for DVT.Interventions: Duplex scan of lower extremities.Outcome measures: The dependent variable was positive duplex screening for either any DVT (distal and/or proximal) or proximal DVT.Results: Of the 189 patients, 31 patients (16.4%) had a positive scan for any (proximal and/or distal) DVT, with 9 (4.8%) positive for a proximal DVT and 22 (11.6%) positive for isolated distal DVT. Of those with isolated distal DVT, 31.8% later developed propagation with either proximal DVTs or pulmonary embolism (mean = 22 days). Factors significantly associated with positive duplex scans for any (proximal and/or distal) DVT include more severe neurological injury (AIS A, B or C versus AIS D: χ² = 7.1791, df = 1, P = 0.007) and older age (age ≥50 years old: χ² = 14.9410, df = 1, P = 0.000).Conclusion: In acute traumatic SCI, older age and more severe neurological impairment (AIS A, B, and C) are independent risk factors for positive duplex screening for any (proximal and/or distal) DVT detected on rehabilitation admission. Individuals with an acute distal DVT have a high likelihood for future thrombus progression. Routine surveillance for these patients may be warranted.